Inspection Reports for
Evergreen Court
1415 W. Scott Ave, Fresno, CA 93711, CA, 93711
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
418% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
100% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 10
Date: Oct 28, 2025
Visit Reason
The inspection was an unannounced annual visit conducted by Licensing Program Analysts to evaluate compliance with licensing requirements at Evergreen Court facility.
Findings
The inspection found multiple deficiencies including unlocked and accessible medications and chemicals posing immediate health risks, missing physician orders for medications, medication errors, lack of required resident records, a resident with a stage 3 pressure injury retained in the facility, facility maintenance issues such as dust and spider eggs, and failure to report hospitalizations to the licensing agency.
Deficiencies (10)
Medications stored in kitchen cabinet unlocked and accessible to residents.
No physician's written order for medication Alprazolam and crushed medications for resident R2.
Medication Tamsulosin administered inconsistently with physician's directions, posing immediate health risk.
Disinfectants, chemicals, sharps, nutritional supplements, and paints unlocked and accessible to residents.
Resident R6 with stage 3 pressure injury retained in facility.
Missing appraisal, needs and services plans, and medical consent forms for several residents.
Facility not clean or in good repair: dusty air filter, spider eggs, broken fence board.
Failure to submit written reports to licensing agency for hospitalizations of residents R3 and R5.
Resident R1 receiving home health care without a current home health care plan on file.
Resident R6's belongings stored in locked walk-in closet inaccessible to resident.
Report Facts
Residents present: 6
Total capacity: 6
Residents receiving hospice services: 2
Residents receiving home health services: 1
Deficiency due dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Licensee/Administrator | Met with Licensing Program Analysts during inspection and involved in plan of correction |
| Mary Garza | Licensing Program Analyst | Conducted inspection and authored report |
| Santonsh Kumari | Care Giver | Met Licensing Program Analysts at facility entry |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 9
Date: Oct 28, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including staff locking resident doors, toxins accessibility, staff yelling at residents, rough handling, fingerprint clearance issues, medication mismanagement, unmet bathing needs, and lack of privacy in bedrooms.
Complaint Details
The complaint investigation was substantiated. Allegations included staff locking resident doors, toxins accessible to residents, staff yelling and rough handling residents, fingerprint clearance issues, medication mismanagement, unmet bathing needs, and lack of privacy. Deficiencies were cited and immediate civil penalties assessed.
Findings
The investigation substantiated all allegations including locked resident doors, unlocked chemicals and medications accessible to residents, staff yelling and rough handling of residents, staff without proper fingerprint clearance, medication mismanagement, residents not receiving requested bathing frequency, and lack of privacy due to surveillance cameras in bedrooms. Deficiencies were cited and immediate civil penalties assessed.
Deficiencies (9)
Staff locked resident's door to prevent resident from leaving.
Chemicals, sharps, and medications were unlocked and accessible to residents.
Staff yelled at residents and handled residents in a rough manner.
Licensee did not ensure staff had fingerprint clearance.
Medication mismanagement including unlocked medications and failure to properly destroy discontinued medications.
Residents' bathing needs were not met as requested due to limited staffing.
Surveillance cameras in hallway facing directly into bedrooms compromising residents' privacy.
Insufficient and incompetent personnel to meet resident needs.
Residents not accorded dignity in personal relationships due to surveillance cameras invading privacy.
Report Facts
Capacity: 6
Census: 6
Plan of Correction Due Date: Nov 7, 2025
Medication quantity: 2
Medication dose: 100
Shower frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Facility administrator involved in investigation and exit interview |
| Mary Garza | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| M. Yang | Licensing Program Analyst | Evaluator who assisted in complaint investigation |
| Nendr Ghotre | Care Giver | Staff met during investigation |
| Santosha Kumari | Care Giver | Staff met during investigation |
| See Moua | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-05-30 regarding allegations including operating beyond license conditions, language barriers with staff, inadequate food service, and unclean bedding.
Complaint Details
The complaint investigation was unsubstantiated based on the evidence reviewed during the unannounced visit on 2025-10-28.
Findings
The investigation included facility tours, interviews, and documentation review. The allegations were found to be unsubstantiated as the preponderance of evidence standard was not met per California Code of Regulations, Title 22.
Report Facts
Capacity: 6
Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Licensee/Administrator | Met with Licensing Program Analysts during the investigation |
| Mary Garza | Evaluator | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 4
Date: May 31, 2025
Visit Reason
The inspection was an unannounced case management visit conducted due to observations related to resident R1's records, including outdated hospice care plans and missing incident reports, as well as concerns about staff association with the facility and medication administration.
Complaint Details
The visit was complaint-related due to observations of outdated hospice care plans, missing incident reports, and staff not properly associated with the facility. An immediate civil penalty of $500 was assessed for the staff association issue.
Findings
The inspection found multiple deficiencies including an outdated hospice care plan for R1, a staff member not associated with the facility posing an immediate risk, medication administration issues for R1, and fire safety violations involving locked exit doors. Immediate civil penalties totaling $1500 were assessed for criminal record transfer, fire clearance, and staff association violations.
Deficiencies (4)
Outdated hospice care plan for resident R1 not current and complete, posing immediate health and safety risk.
Staff member (Staff 1) not associated with the facility on Guardian Roster, posing immediate risk to residents.
Fire clearance violation due to locked exit doors preventing residents from exiting, posing immediate health and safety risk.
Failure to report incidents as required, including head wound treatment for R1, posing immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Civil penalty amount: 500
Civil penalty amount: 500
Residents observed: 6
Insulin dosage: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steve Patel | Administrator | Met during inspection and named in findings related to hospice care plan and medication administration |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 4
Date: May 31, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to observations related to resident records, unusual incident reports, and concerns about staff association and medication administration.
Findings
The inspection found multiple deficiencies including an outdated hospice care plan, a staff member not associated with the facility posing immediate risk, medication administration issues, fire exit doors locked preventing egress, and failure to report incidents. Immediate civil penalties of $500 each were assessed for criminal record transfer and fire clearance violations.
Deficiencies (4)
Outdated hospice care plan for resident R1, posing immediate health and safety risk.
Staff member on Guardian Roster not associated with the facility, posing immediate risk.
Fire clearance violation due to locked exit doors preventing residents from exiting.
Failure to submit required incident reports related to resident R1's head wound treatment.
Report Facts
Civil penalty amount: 500
Civil penalty amount: 500
Residents present: 6
Facility capacity: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steve Patel | Administrator | Named in relation to findings including outdated hospice care plan and medication administration |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Date: Jan 27, 2025
Visit Reason
The visit was an office meeting conducted to discuss concerns regarding the facility, including deficiencies cited during the annual inspection completed on 10/22/2024 and a case management visit on 01/08/2025.
Findings
Deficiencies were cited related to personal accommodations, oxygen administration signage, resident records including incomplete and inaccurate documentation, and an open patio area lacking railing and lighting. The facility declined Technical Support services and was informed that failure to correct deficiencies may result in administrative actions.
Deficiencies (4)
Personal Accommodations and Services: storage area accessible through bedroom
Oxygen Administration - Gas and Liquid: signs posting and reporting to Fire Department
Resident Records: pre-admission, reappraisals, medical assessments, TB, incomplete and inaccurate documentation
Personal Accommodations and Services: Open patio area without railing/lighting
Report Facts
Deficiencies cited: 4
Plan of Correction (POC) due date: Feb 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met during inspection and named in relation to findings and plan of correction |
| Rajat Roychoudhury | Licensee | Present during meeting and named in relation to findings |
| Mary Garza | Licensing Evaluator | Conducted inspection and signed report |
| See Moua | Licensing Program Manager (LPM) | Present during meeting and named in relation to findings |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 4
Date: Jan 27, 2025
Visit Reason
The visit was an unannounced office meeting conducted to discuss concerns regarding the facility, including deficiencies cited during prior visits such as the annual inspection on 10/22/2024 and a case management visit on 01/08/2025.
Findings
Deficiencies were cited related to personal accommodations, oxygen administration, and resident records. The facility declined Technical Support services and was reminded of the importance of compliance with Title 22 regulations. A new Plan of Correction due date was set for 02/07/2025 for unresolved issues including an open patio without hand railing or lighting and incomplete resident records.
Deficiencies (4)
Personal Accommodations and Services: storage area accessible through bedroom
Oxygen Administration - Gas and Liquid: signs posting and reporting to Fire Department
Resident Records: pre-admission, reappraisals, medical assessments, TB, etc. incomplete or missing
Personal Accommodations and Services: Open patio area without railing/lighting
Report Facts
Capacity: 6
Census: 6
Plan of Correction due date: Feb 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with during inspection and named in relation to facility operations and deficiencies |
| Rajat Roychoudhury | Licensee | Present during informal meeting and named in relation to facility operations and deficiencies |
| See Moua | Licensing Program Manager | Named in relation to inspection and deficiency findings |
| Mary Garza | Licensing Program Analyst | Named in relation to inspection and deficiency findings |
Inspection Report
Follow-Up
Census: 5
Capacity: 6
Deficiencies: 8
Date: Jan 8, 2025
Visit Reason
This unannounced case management visit was conducted to review and clear Plans of Correction (POCs) from a previously conducted visit and to complete a health and safety check on residents in care.
Findings
Several deficiencies were observed including unlocked chemicals and medications accessible to residents, improperly stored and undated food, inadequate air circulation in freezer, storage area accessible through a resident's bedroom, lack of hand railings and lighting on open patio, insufficient towels and linens for residents, and lack of physician orders for postural supports such as bed railings. Maintenance issues such as dirty attic door, hanging vents, and non-self-latching gates were also noted.
Deficiencies (8)
Chemicals/items posing a danger were unlocked and accessible in bathroom #3 countertop, storage area in backyard, and storage shed.
Food in refrigerator was improperly stored and undated.
Freezer was packed and not allowing proper air circulation to maintain temperature.
Storage area accessible through resident bedroom #6.
Open patio on back of facility lacked hand railings and lighting.
Facility lacked adequate towels and linens for residents.
Residents' beds with hand railings lacked written physician orders for postural supports.
Attic space door dirty and in need of painting; vents hanging and dirty; doorway needing touch-up paint; gates not self-latching.
Report Facts
Deficiencies cited: 8
Capacity: 6
Census: 5
Plan of Correction Due Date: Jan 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Named in relation to findings and plans of correction. |
| Shailesh Patel | Designee | Met with Licensing Program Analyst during inspection. |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and authored the report. |
Inspection Report
Follow-Up
Census: 5
Capacity: 6
Deficiencies: 8
Date: Jan 8, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to review and clear plans of correction (POCs) from a previously conducted visit.
Findings
Several deficiencies were observed including unlocked chemicals posing danger, improperly stored food, inadequate air circulation in freezer, a resident bedroom used as a passageway, lack of hand railings and lighting on patio, insufficient towels for residents, missing physician orders for postural supports, and maintenance issues such as dirty attic door, hanging vents, and non-self-latching gates.
Deficiencies (8)
Chemicals/items posing a danger on bathroom #3 countertop, in storage area in back yard and in storage shed all unlocked and accessible to residents.
Food in refrigerator was not properly stored/dated.
Freezer packed and not allowing for proper ventilation to maintain temperature.
Bedroom #6 observed with storage area only accessible through resident bedroom.
Open patio on back of facility without hand railings or lighting.
Facility has 7 towels for 5 residents, insufficient for adequate hygiene.
Residents beds with hand railing but no written physician order for postural support.
Attic space door dirty and in need of painting; vent in hallway near office hanging and in need of cleaning; AC/heating vents dirty and in need of cleaning; doorway from living room to sitting area in need of touch up paint; gates on right and left side of facility not self-latching.
Report Facts
Residents present: 5
Facility capacity: 6
Plan of Correction due date: Jan 20, 2025
Number of towels: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the inspection and signed the report |
| Minakshi Roychoudhury | Administrator | Facility administrator present during inspection and exit interview |
| Shailesh Patel | Designee | Facility designee met during inspection and exit interview |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 11
Date: Oct 22, 2024
Visit Reason
The inspection was an unannounced annual inspection visit conducted to evaluate the health and safety conditions of the Evergreen Court facility.
Findings
The facility was generally clean, odor-free, and well-maintained with operational safety equipment; however, several deficiencies were noted including unlocked chemicals in restrooms and offices, vents needing dusting, improperly stored food, and safety hazards such as an open patio without railing and an unsecured gate.
Deficiencies (11)
Chemicals observed in 3 of 3 restrooms unlocked and accessible.
Vents in hallways in need of dusting/air filters.
Restroom #2 tub in need of cleaning.
Food in freezer not dated/stored properly.
Chemicals/items posing a harm in office unlocked and accessible.
Walls and doors in need of wiping down.
Chemical observed in resident #6 bedroom.
Storage area accessible through resident #6 bedroom.
Chemicals/items posing a harm next to storage shed and outside back door accessible and unlocked.
Open patio on back of facility observed without railing and lighting posing a hazard.
Left side gate not self-latching.
Report Facts
Capacity: 6
Census: 5
Water temperature: 116.4
Fire extinguisher last serviced: Sep 18, 2024
Last fire drill: Jul 17, 2024
Plan of Correction Due Date: Nov 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Facility Administrator present during inspection and exit interview |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and signed the report |
| Noelia Luna | Direct Care Staff | Met Licensing Program Analyst upon arrival |
Inspection Report
Original Licensing
Census: 5
Capacity: 6
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection was an announced pre-licensing visit conducted as a change of ownership inspection for the Evergreen Court facility.
Findings
The facility met all pre-licensing requirements, including adequate furnishings, safety measures, and supplies. The Licensing Program Analyst found no deficiencies and will submit documentation for final license review.
Report Facts
Facility capacity: 6
Resident census: 5
Fire extinguisher service date: Apr 10, 2023
Hot water temperature range: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with Licensing Program Analyst during inspection |
| Shailesh Patel | Administrator | Met with Licensing Program Analyst during inspection |
| Alexandria Walton | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Melinda Hoffmann | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 6
Capacity: 6
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The visit was conducted as part of the original licensing process for Evergreen Court Facility, including verification of applicant and administrator identity and understanding of community care facility licensing laws.
Findings
The applicant and administrator demonstrated understanding of licensing laws, facility operation, staffing, training, and pre-licensing readiness during a telephone interview. Signed documentation and photo ID were obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Named as applicant/administrator participating in licensing interview and verification |
| Rajat Roychoudhury | Named as participant in licensing interview | |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager |
| Dianne Ramos | Licensing Program Analyst | Named as Licensing Program Analyst |
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