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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:30:47 PM

Document Has Been Signed on 01/09/2025 03:30 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:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 5DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Licensee, Lanina GarciaTIME VISIT/
INSPECTION COMPLETED:
03:21 PM
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On 1/9/25 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced case management visit. LPA met with Licensee, Lanina Garcia and Administrator, Phoeun Marez explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care.

This case management visit was is being conducted for issues that were observed during a complaint visit. The following issues were observed:

Living room carpet has hole near transition from living room to kitchen. Transition from living room to kitchen in need of replacement. Carpet in master bedroom doorway was lifted and in need of repair. Outside back patio observed with moss in need of cleaning. Refrigerator in garage leaking liquid in need of replacement. Garage observed with clutter in need of removal.

Deficiencies cited per Title 22. Exit interview completed with Licensee, Lanina and Administrator, Phoeun. A copy of this report, deficiencies 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 03:30 PM - It Cannot Be Edited


Created By: Mary Garza On 01/09/2025 at 03:00 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: 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
87303(a)

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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.
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Licensee stated they will be having maintenance work on the transition and carpet. Patio will be pressure washed. Pictures will be provided as proof of correction. New refrigerator will be purchased. Licensee stated they will supply the receipt and picture as proof of correction. Licensee stated storage unit will be rented. Receipt and picture showing garage is cleaned will be sent as proof of correction.
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This requirement was not met as evidence by: LPA observation of tear in carpet near transition from living room to kitchen in need of repair. Transition from living room to kitchen in need of replacement. Carpet in master bedroom doorway was lifted and in need of repair. Outside back patio observed with moss in need of cleaning. Refrigerator in garage leaking liquid in need of replacement. Garage observed with clutter in need of removal.
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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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