<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209624
Report Date: 10/01/2026
Date Signed: 10/01/2026 04:56:59 PM

Document Has Been Signed on 10/01/2026 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EVERGREEN CAREHOME IFACILITY NUMBER:
107209624
ADMINISTRATOR/
DIRECTOR:		KAUR SUKHPREETFACILITY TYPE:
740
ADDRESS:4767 Hampton WAYTELEPHONE:
(209) 851-0087
CITY:ClovisSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
10/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator - Sukhpreet KaurTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/01/2026, Licensing Program Analyst (LPA) M Vega conducted an unannounced Annual visit. LPA was allowed entry by facility staff and Administrator was contacted of LPA presence in facility. Administrator - Sukhpreet Kaur arrived a short time later.

LPA reviewed Staff and Resident files. Resident files observed to have updated information. MAR was reviewed and was accurate and up to date at time of inspection.

LPA began the tour at the entrance of the facility that has one entrance point. LPA toured the inside and outside of the facility.

The facility was observed at a comfortable temperature of 75 degrees Fahrenheit. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas furnished and well-lit throughout. LPA observed the kitchen to be absent of any trash or debris, sharp objects are secured and inaccessible to residents in care. At this time, seven day supply of non-perishable food were observed.

Resident’s all bedrooms were observed to be furnished with bed, dresser, night stand, and overhead lightning. Mattresses, box springs, sheets, and linens, were absent of any tears and stains.

Bathrooms and showers were equipped with non-skid flooring and securely fastened grab bars. The bathroom water temperature was tested at 112.2 degree Fahrenheit. Towels, linens, and personal hygiene supplies were observed in storage. This facility does not have any bodies of water.

All Fire extinguishers are current with service date of 09/09/2026. Carbon monoxide and smoke detectors were observed to be operational.

Continuation on LIC 809C

Shawna Doucette
Martin Vega
DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: EVERGREEN CAREHOME I
FACILITY NUMBER: 107209624
VISIT DATE: 10/01/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate and up to date information for your facility. In an effort to maintain your facility file, please submit the most current and complete forms and/or information as identified below:

Residential Care Facility for the Elderly (RCFE)

LIC 308 Designation of Facility Responsibility

LIC 309 Administrative Organization

LIC 400 Affidavit Regarding Client/Resident Cash Resources

LIC 402 Surety Bond

LIC 500 Personnel Report

LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly

LIC 9020 Register of Facility Clients/Residents

Copy of current Liability Insurance

Copy of current Administrator Certificate

Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 10/15/2026 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

No deficiencies issued during this inspection. An exit interview was conducted with the Administrator - Sukhpreet Kaur.

A copy of this report was given to Administrator whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Martin Vega
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 3