Evergreen Care Center
5265 East Huntington Avenue, Fresno, CA 93727 · Fresno County · 49 certified beds · avg 46 residents/day · certified since Nov 12, 2019
Part of chain: AJC HEALTHCARE (14 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 11, 2025 · F-0699 · triggered by a complaint
The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Why it matters: Care that ignores a resident's trauma or culture can cause distress and damage their trust in caregivers.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 3, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 23, 2019 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 7, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (35)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 27, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 17, 2025 | E · Potential for harm, repeated | The facility did not help residents with transportation to and from laboratory services outside the facility. · from a complaint |
| Mar 11, 2025 | ▲ G · Actual harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| Mar 11, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Mar 11, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 11, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 26, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Nov 13, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 17, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 17, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 17, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 17, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 17, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 17, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 17, 2024 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Jan 16, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Oct 11, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Oct 11, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| May 23, 2019 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 23, 2019 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| May 23, 2019 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 23, 2019 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 23, 2019 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 23, 2019 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| May 23, 2019 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| May 23, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 23, 2019 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 1 | G ▲ |
| 2023 | 5 | 0 | D |
| 2024 | 11 | 0 | F |
| 2025 | 7 | 1 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.42 | 4.31 | 3.95 | bottom 7% in California; bottom 33% in the U.S. |
| Registered Nurse hours | 0.50 | 0.61 | 0.69 | top 46% in California; bottom 38% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.90 | 3.50 | bottom 10% in California; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.51 | 0.48 | top 33% in California; top 36% in the U.S. |
| Total nursing staff turnover (%) | 51.5 | 36.7 | 45.8 | bottom 12% in California; bottom 33% in the U.S. |
| RN turnover (%) | 66.7 | 38.1 | 42.9 | bottom 9% in California; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.20, RN 0.62, weekend 3.89. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chesley, Aaron | Individual | 5% or Greater Indirect Ownership Interest | — | 02/01/2021 |
| Evergreen Care Center Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/17/2019 |
| SWC Ca Opco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/01/2021 |
| Chesley, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Evergreen Care Center Holdings LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/17/2019 |
| Gamett, James | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Smith, Phylicia | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you learn about each resident's background and history, and how does that shape their care?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you arrange transportation when a resident needs tests or appointments outside the facility?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Pacific Gardens Nursing and Rehabilitation Center | 0.2 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Orchard Post Acute | 0.6 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Stonehaven Senior Living | 1.1 mi | Fresno, CA | —/5 | ||
| Sierra Vista Healthcare | 1.9 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| California Home for the Aged | 2.8 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Grace Healthcare Center | 3.0 mi | Fresno, CA | ★☆☆☆☆ | 1/5 | |
| Healthcare Centre of Fresno | 3.9 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Oakwood Gardens Care Center | 3.9 mi | Fresno, CA | ★★★★★ | 4/5 | |
| Covenant Post Acute | 3.9 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Keystone Post-Acute | 4.1 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Community Subacute and Transitional Care Center | 4.2 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Fresno Postacute Care | 4.5 mi | Fresno, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555920.