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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107207121
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:34:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20241017120820
FACILITY NAME:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR:RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Licensee, Lanina GarciaTIME COMPLETED:
03:34 PM
ALLEGATION(S):
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Staff are unable to communicate effectively with the residents
INVESTIGATION FINDINGS:
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On 1/9/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit. Visit is being conducted to deliver complaint findings. LPA met with Licensee, Lanina Garcia explained reason or visit and was permitted entry into the facility. Administrator, Phoeun Marez was contacted and arrived some time later. LPA completed a health and safety check on residents in care. Residents observed in living room watching television and in rooms.

During investigation LPA completed interviews, conducted visits and reviewed documentation (Resident roster, staff roster with contact information, staff schedule for September/October 2024, physician’s reports, needs and service plans, visitors log). During visits LPA observed S1 and S2 unable to effectively communicate with residents, visitors and LPA. Staff are utilizing a translating device to communicate. Interviews conducted expressed concern of “staff not being able to communicate with emergency services ” or “meet the residents needs”.

CONT...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20241017120820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: NINA'S HOME
FACILITY NUMBER: 107207121
VISIT DATE: 01/09/2025
NARRATIVE
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CONT...

The Department has found this allegation has met the preponderance of evidence standard per Title 22. This allegation is SUBSTANTIATED. Deficiency cited per Title 22.

Exit interview completed with Administrator, Phoung Marez. A copy of this report, deficiency and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20241017120820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NINA'S HOME
FACILITY NUMBER: 107207121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Staff (Simon) that was previously working and not able to communicate is no longer at the facility. Licensee stated they will submit a copy of the new schedule with the new staff that are working at the facility as proof of correction.
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This requirement was not met as evidence by: LPA observation and interviews conducted. Observation of S1 and S2 utilizing a translation device to communicate with residents, visitors and other staff.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3