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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209371
Report Date: 10/28/2025
Date Signed: 01/05/2026 02:11:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2025 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20250530080715
FACILITY NAME:EVERGREEN COURTFACILITY NUMBER:
107209371
ADMINISTRATOR:ROYCHOUDHURY,MINAKSHIFACILITY TYPE:
740
ADDRESS:1415 WEST SCOTT AVENUETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator, Minakshi RoychoudhuryTIME COMPLETED:
01:01 PM
ALLEGATION(S):
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Staff lock resident's door to prevent resident from leaving
Staff do not ensure toxins are inaccessible to residents
Staff yells at residents
Staff handles residents in a rough manner
Licensee does not ensure that staff have fingerprint clearance
Staff are mismanaging residents' medication
Staff do not ensure residents' bathing needs are met
Staff do not ensure residents' have privacy in their bedroom(s)
INVESTIGATION FINDINGS:
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On 10/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Yang arrived at the facility to complete an unannounced complaint visit to deliver findings. LPAs met with Care Givers, Nendr Ghotre and Santosha "Nikki" Kumari, explained reason for visit and was permitted entry into the facility. Licensee/Administrator, Minakshi Roychoudhury was contacted and arrived some time later. Tour of the facilty was completed by LPAs inside and out. A health and safety check was completed on residents in care. Residents observed in common area watching television and in rooms.

During investigation LPA completed visits, requested and reviewed documentation and completed interviews.

During visit conducted on 5/31/25, LPA observed bedroom #1 with the door knob installed with the lock on the outside of the door. Door knob lock could only be unlock from the outside of the room in the hallway by staff. Bedroom is unable to unlock from the inside of the room. Locks were observed on the top of the exit sliding doors. Exit sliding doors were locked during visit on 05/31/25. Based on LPA observations, the allegation staff locked resident’s door to prevent resident from leaving is SUBSTANTIATED. Deficiency was cited and an immediate civil penalty was assessed during case management visit on 05/31/25. CONT...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20250530080715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371
VISIT DATE: 10/28/2025
NARRATIVE
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CONT...
During visits conducted on 5/31/25 and 10/28/25 LPA observed chemicals, sharps and medications unlocked and accessible to residents in care posing a danger. This allegation staff do not ensure toxins are inaccessible to residents is SUBSTANTIATED. Deficiency cited on attached 9099D.

Interviews were conducted with staffs and residents. LPA was informed staff argues with their significant other and afterward would get upset with residents and yell at them. Residents are handled in a rough manner by staff after staff’s arguments with their significant other. During complaint visit on 05/13/25, LPA observed staff attempting to lift a resident in living room from the resident’s chair. LPA observed the staff having difficulty lifting the resident. The allegations staff yells at residents and staff handles residents in a rough manner are SUBSTANTIATED. Deficiency cited on attached 9099D.

During complaint visit on 5/31/25, LPA observed S1 providing care to the residents. Records were reviewed, facility staff roster showed S1 was fingerprint cleared but not associated to the facility. This allegation Licensee does not ensure that staff have fingerprint clearance is SUBSTANTIATED. Deficiency was cited on a case management visit conducted on 5/31/25.

During complaint visit conducted on 5/31/25, LPA completed a tour of the facility. LPA observed Lantus Solostar 100unit.ml medications for R4 unlocked in a medication lock box inside the bottom shelf of the refrigerator. During an interview conducted with Administrator, Administrator informed LPA, R4 was no longer taking the medication per physicians’ orders. R4’s file was reviewed, no order for Lantus medication was discontinued. During medication audit, discontinued medications for 2 of the 6 residents were not properly destroyed and recorded. This allegation staff are mismanaging residents medications is SUBSTATIATED. Deficiency issued on attached 9099D.

During complaint investigation, interviews were conducted, and records were reviewed. Interviews conducted with staff and residents confirmed residents were being showered two times a week. Licensee and Administrator confirm 2 out of 6 residents requesting or needing to be showered more than 2 times a week and are not being showered as request/needed due to "limited staffing to accommodate the residents’ request". Residents receiving hospice care are being showered by their hospice care agency weekly. Facility shower log records show all residents are showered two times weekly. Staff records in the facility computer system show when staff are giving showers. Based on interviews conducted and records reviewed, the allegation staff do not ensure residents’ bathing needs are met is SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

During visit conducted on 5/31/25, LPA observed surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. The allegation staff do not ensure residents have privacy in their bedroom(s) is SUBSTANTIATED. Deficiency cited on attached 9099D.

The preponderance of evidence standard has been met per Title 22. Deficiencies cited per California Code of Regulations, Title 22. If not corrected, deficiencies will have a direct impact to residents in care.Exit interview completed with Licensee/Administrator, Minakshi. Plans of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies and appeal rights were provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20250530080715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87309(a)
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87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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Licensee immediately removed and locked up items during visit conducted on 05/31/2025. This POC has been cleared.
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This requirement was not met as evidence by: LPA observations. The licensee did not comply with the section cited above in that LPA observed chemicals, sharps and medications throughout the facility during complaint visit on 5/31/25, unlocked and accessible to residents in care. This poses a potential health safety and or personal rights risk to residents in care.
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Type B
11/07/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/2025. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/2025.
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This requirement was not met as evidence by: interviews conducted and LPA observations. The licensee did not comply with the section cited above in that interviews confirmed staff would be upset and yell at the residents. LPA observation of resident being transferred by staff with difficulty and a rough manner. The poses a potential health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250530080715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/25. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/25.
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This requirement was not met as evidence by: review of records and LPA observations. The licensee did not comply with the section cited above in that LPA observed 2 unused Lantus Solostar 100unit.ml insulin pens for R4 in refrigerator filled on 3/11/5. Interviews with Licensee, Administrator, staff and R4 disclosed R4 does not get injections as prescribed. No discharge of medication was observed in R4’s file. Interviews with Licensee, Administrator, staff and residents disclosed residents are only being showered 2x weekly and not as needed or requested. This poses a potential health safety and or personal rights risk to residents in care.
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Type B
11/07/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee stated they will provide a plan of correction in writting to include the type of training that will be provided to staff by 11/03/25. An in-service sign in sheet and training material will be provided to CCL by POC date of 11/07/25.
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This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. This poses a potential health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4