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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 09/12/2025
Date Signed: 09/12/2025 07:15:51 PM

Document Has Been Signed on 09/12/2025 07:15 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:GIFT OF GRACE CARE HOMEFACILITY NUMBER:
107202381
ADMINISTRATOR/
DIRECTOR:		PAMELA LEWISFACILITY TYPE:
740
ADDRESS:1480 W. SAN MADELE AVENUETELEPHONE:
(559) 449-3506
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
09/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Phoeun MarezTIME VISIT/
INSPECTION COMPLETED:
05:56 PM
NARRATIVE
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On 09/12/2025 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Care Giver, Josephine Jo and Care Giver, Ryan Figueroe. LPA introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Phoeun Marez was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 6 residents present during visit. 2 residents receiving hospice services at time of visit.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: Interviews with 3 of 3 residents disclosed they are not able to request, or refuse services. Facility does not have a device for the residents to use or access. Facility does not have activities for the residents to participate. R3's file missing home health care plan reflecting services, frequency and duration of care. Training is not being completed and documented with staff by hospice. 2 of 2 staff files reviewed do not have the required training. Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a potential risk to the health, safety and/or personal rights of residents in care.

CONT...

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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 6
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 6
Document Has Been Signed on 09/12/2025 07:15 PM - It Cannot Be Edited


Created By: Mary Garza On 09/12/2025 at 05:06 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: GIFT OF GRACE CARE HOME
FACILITY NUMBER: 107202381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.269(a)(31)
Resident's Bill of Rights
(31) To request, refuse, or discontinue a service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above in that 3 of 6 residents are not permitted to request or refuse services. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator stated they will complete training with all staff. In service sign in sheet and training material will be provided to CCL by POC date as proof of correction.
Type B
Section Cited
HSC
1569.319(b)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted, the licensee did not comply with the section cited above in that the facility does not have a device for the residents to use or access. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator stated they will purchase a device and make accessible to residents in care. Administator stated they will provide a receipt for the device purchased and submit to CCL by POC date as proof of correction.
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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/12/2025 07:15 PM - It Cannot Be Edited


Created By: Mary Garza On 09/12/2025 at 05:06 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: GIFT OF GRACE CARE HOME
FACILITY NUMBER: 107202381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted, the licensee did not comply with the section cited above in the facility does not have activities for the residents to participate. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administator stated that in order to be more person centered they will discuss activities with residents and generate an activity calendar on their preferences. A copy of the activity calendar will be provided to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
87609(b)(4)(A)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). (A) The written agreement shall reflect the services, frequency and duration of care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that R3's file was missing the home health care plan relecting services, frequency and duration of care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator stated they will request a copy of the home health care plan that was in place for R3. A copy will be provided to CCL by POC date as proof of correction.
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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/12/2025 07:15 PM - It Cannot Be Edited


Created By: Mary Garza On 09/12/2025 at 05:06 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: GIFT OF GRACE CARE HOME
FACILITY NUMBER: 107202381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that training is not being completed and documented with staff by hopice.for 2 of 2 hospice residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator stated they will reach out to hospice agencies and request an all staff in service training for the residents in care. A copy of the in service sign in sheet and training material will be provided to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
87705(b)(1)(A)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reivew, the licensee did not comply with the section cited above in that 2 of 2 staff files reviewed do not have the required dementia training. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator stated that all staff will be completing the required dementia training. Certificates of completion will be provided to CCL by POC date as proof of correction.
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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: GIFT OF GRACE CARE HOME
FACILITY NUMBER: 107202381
VISIT DATE: 09/12/2025
NARRATIVE
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CONT...

LPA requested the following documents to be submitted to CCL by 09/19/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) and a copy of liability insurance in order to update the facility file.

Exit interview was conducted with Administrator, Phoeun. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, TV's and appeal rights were discussed and provided to Administrator.

TSP was discussed. An office meeting will be scheduled and TSP will be offered at that time.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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