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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 05/28/2025
Date Signed: 05/28/2025 10:52:05 AM

Document Has Been Signed on 05/28/2025 10:52 AM - 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:SERENITY LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR/
DIRECTOR:		JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 4DATE:
05/28/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Designee, Elaine SalcedoTIME VISIT/
INSPECTION COMPLETED:
11:01 AM
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 5/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Medina arrived for an unannounced case management visit. LPAs met with Designee, Elaine Salcedo, explained reason for visit and were permitted entry into the facility. Licensee, Josiane Jones was contacted and arrived some time later. LPAs completed a tour of the facility inside and out. Currently the facility has 4 residents in care. 3 observed in living area sitting in recliners and 1 in bed sleeping. Currently there are no residents receiving hospice services or home health services.

This case management visit is being conducted to complete a health and safety check on residents in care and to gather documentation (residents census, staff schedule with contact information, emergency contact information, resident roster and staff roster) and verify an uncleared staff is not working at the facility.

During visit LPAs observed the following: bed in bedroom #2 was without box springs (Licensee stated son preferred this way due to height with box spring). A smell of urine/feces, sufficient lighting was not supplied and the light switch was not functioning in bedroom #3. Room was observed to be dark with only 1 lamp providing light (Licensee and staff stated it was getting repaired today). Medicine closet was observed unlocked and accessible to residents in care (staff stated they were working in there upon LPAs arrival). Deficiencies cited per Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D's. If not corrected the violations will have a direct and immediate risk to the health, safety and or personal rights of residents in care.

Exit interview completed with Licensee, Josiane. A copy of this report, deficiencies and appeal rights were discussed and provided. A plan of correction was developed by the Licensee and reviewed with the LPAs.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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 4
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 4
Document Has Been Signed on 05/28/2025 10:52 AM - It Cannot Be Edited


Created By: Mary Garza On 05/28/2025 at 09:41 AM
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: SERENITY LIVING
FACILITY NUMBER: 107201663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2025
Section Cited
CCR
87462(h)(2)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
1
2
3
4
5
6
7
Training will be completed with all staff. In- service sign in sheet will be completed and submitted to CCL with training material by POC date as proof of correction.
8
9
10
11
12
13
14
This requirement was not met as evidence by: LPAs observation, the licensee did not comply with the section cited above in that LPAs observed the medication closet off the kitchen to be unlocked and accessible to residents in care. This poses an immediate health, safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
06/13/2025
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 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.
1
2
3
4
5
6
7
Bedding was immediately removed. In the future bedding will be removed and changed immediately and sanitation will be completed. Training will be completed with all staff. In-serivce sign in sheet and training material will be submitted to CCL by POC date as proof of correction.
8
9
10
11
12
13
14
This requirement was not met as evidence by: LPAs observation, the licensee did not comply with the regulation cited above in that, a smell of urine and feces, sufficient lighting was not supplied and the light switch was not functioning in bedroom #3. This poses a potential health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/28/2025 10:52 AM - It Cannot Be Edited


Created By: Mary Garza On 05/28/2025 at 09:56 AM
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: SERENITY LIVING
FACILITY NUMBER: 107201663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87307(a)(3)(A)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (a) Living accommodations and grounds...The following provisions shall apply: (3) Equipment and supplies necessary...: (A) A bed for each resident...Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.
1
2
3
4
5
6
7
Licensee stated they will obtain a letter from the family stating they do not want a box spring for the bed. This will be kept in resident file for future reference. A copy of the letter will be submitted to CCL as proof of correction.
8
9
10
11
12
13
14
This requirement was not met as evidence by: LPAs observation, the licensee did not comply with the regulation cited above in that, of bed in bedroom #2 was without box springs. This poses a potential health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4