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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405566
Report Date: 02/04/2026
Date Signed: 02/04/2026 07:05:17 PM

Document Has Been Signed on 02/04/2026 07:05 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PRINCE & PRINCESS HOME FOR THE ELDERLYFACILITY NUMBER:
100405566
ADMINISTRATOR/
DIRECTOR:		PRINCE, BETTYFACILITY TYPE:
740
ADDRESS:4686 E CORTLANDTELEPHONE:
(559) 231-5728
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 6CENSUS: 4DATE:
02/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee Betty PrinceTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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On 2/4/2026 Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee Betty Prince.

LPA conducted a tour with Licensee; there were three residents present during inspection. The facility was observed to be at a comfortable temperature with no passageway obstructions or fire hazards. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured First Living area, two shared resident bedrooms and bathroom. All common areas were properly furnished and well-lit throughout. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed one resident Bedroom missing baseboards. Resident bedroom windows observed with bent and broken window screen. One bathroom toured and observed to be operational. Non-skid mat and grab bars observed in bathroom shower. Tour continued to backyard. Outside wall observed with two holes. LPA observed laundry strewn on the patio floor. Unlocked tools, knife observed. Tour continued to second living area which was observed with dust and debris. Unlocked laundry area observed with cleaning supplies, chemicals, bug spray, tools, and bleach. Files, Medication, and first aid observed in Facility office. LPA observed a 2-day supply of perishable foods. LPA did not observe 7-day supply of non-perishable foods. Freezer temperature was maintained at -1 degrees F. Refrigerator temperature was 45 degrees F. Fire extinguisher in the Kitchen was last serviced on 08/4/2025.

Backyard observed to have sufficient seating in shaded patio area. Pool was observed locked. Medication was reviewed. LPA reviewed staff and resident files and observed missing CPR, TB for Licensee.

Report Continued on 809C

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2026
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 12
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 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above; LPA observed unlocked chemicals, cleaning solutions, tools, knife which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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Licensee agrees to lock all tools, sharps and chemicals.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above; Licensee and spouse did not have a current first aid which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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Licensee agrees to submit a plan of intent to complete CPR training and submit records when training is complete.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensee did not have record of health screening or TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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Licensee agrees to locate health screening and submit documentation by due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA did not observe 7 day supply of nonperishable foods which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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Licensee agrees to re-stock nonperishable food and submit records or pictures by due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview , and record review, the licensee did not comply with the section cited above in one out of one. LPA observed Centrally Stored list was incomplete (Missing start date) and no MARs for February 2026 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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Licensee agrees to locate missing Centrally stored list and bring file up to date and ensure Centrally stored is complete and ensure MARS for Feb 2026 is completed and copies submitted to CCLD by due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 4 residents did not have recored of TB results which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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4
Licensee agrees to submit by due date statement of scheduled appointments. Once TB results are obtained, Licensee will submit results to LPA.
Type A
Section Cited
CCR
87458(a)
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 4 residents did not have a medical assessment on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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2
3
4
Licensee agrees to submit by due date statement of scheduled appointments. Once Physicians Report are completed Licensee will submit copies to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and interview, the licensee did not comply with the section cited above in one out of one which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to research companies that can provide the required coverage and submit documentation of coverage when purchased.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and interview, the licensee did not comply with the section cited above. LPA observed missing baseboards, holes in the back wall, clutter in backyard, dust and debris in second living area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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2
3
4
Licensee agrees to replace baseboards, clean facility and submit pictures when completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in three out of three. LPA did not observe Personal Rights, nondiscrimination notice, complaint poster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to post all required postings and submit pictures by due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in Emergency and Disaster plan was incomplete; missing evacuation procedures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to complete Evacuation procedures on LIC 601E page 5, including identification of an assembly point or points that shall be included in the facility sketch.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in one out of one. Last documented fire Drill was conducted on 4/1/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to conduct a drill and submit documentation by due date and continue to conduct quarterly drills.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of three did not have a appraisal of resident needs an service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to complete a resident needs and service plan for all residents in care
Type B
Section Cited
CCR
87412(d)
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of one. Licensee’s Administrator certificate is expired as of 10/09/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
1
2
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Licensee states she was short on Administrator Certificate fees and will follow up with Sacramento to complete.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2026 07:05 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2026 at 05:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in two bedrooms observed with bent and torn window screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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Licensee agrees to repair/ replace window screen and submit pictures by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566
VISIT DATE: 02/04/2026
NARRATIVE
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Medication review revealed missing MARs for February 2026 and incomplete Centrally Stored Log. Resident records were missing Physicians reports, TB results, and resident appraisal and needs plans. Licensee stated Labiality Coverage is not maintained for the required amounts. LPA did not observe personal rights, nondiscrimination notice, and complaint postings. Last Fire Drill was conducted on 4/1/2025. Emergency and Disaster plan was incomplete regarding evacuation proceedings. Administrator Certificate expired on 10/9/2024.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/25/2026: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview conducted and plan of corrections was reviewed and developed with Licensee/Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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