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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:06:40 PM

Document Has Been Signed on 09/18/2025 04:06 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:
09/18/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Licensee, Lanina GarciaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 9/18/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Care Giver, Mario Contreras, explained reason for visit and was permitted entry into the facility. Licensee, Lanina Garcia was contacted and arrived some time later. LPA completed a health and safety check on residents in care. There are currently 5 residents in care. 3 of 5 residents receiving hospice care at this time.

LPA reviewed resident files including hospice binders, completed interviews and toured the facility.

During review of files it was observed that 2 of the 5 residents are diabetic. Medical records indicate that R1 takes injections 3x daily. Interview with Licensee disclosed that R1's brother-in-law comes to the facility to do the injections for R1. R2 takes medication in the form of a pill. MARS was reviewed and indicated that R1 did not have injectable medications in am, and mid day as prescribed.

Review of records indicate that R1, R2 and R3 are all receiving hospice services. License was informed the hospice wavier at this facility will be reduced from 2 to 1 and could not accept any new hospice residents without an exception effective 2/6/25. Review of Department records do not indicate hospice exceptions were requested for 2 additional residents after this date.

Licensing fees were due for the facility in December 2024. At this time, the facility is late on licensing fees and owes an amount of $741.50.

Deficiencies cited per Title 22. If not corrected, deficiencies will have a direct impact on residents in care.

Exit interview completed with Licensee, Lanina. A plan of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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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)
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Document Has Been Signed on 09/18/2025 04:06 PM - It Cannot Be Edited


Created By: Mary Garza On 09/18/2025 at 03:07 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: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2025
Section Cited
CCR
87606(c)

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(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.
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Licensee will immediately notify fire department they have 2 bedridden residents in the facility. Licensee will submit exceptions for R1 and R2 to CCL by POC date as proof of corrections.
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This requirement was not met as evidence by: record review, interviews and LPA observations. The licensee did not comply with the section cited above in that the facility has a hospice wavier for 1 resident. 3 residents at the facility are currently receiving hospice care. 2 of 3 residents on hospice observed to have grab bar (trapeze) above their bed to assist in repositioning. This poses an immediate health safety and or personal rights risk to residents in care.
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Type A
09/18/2025
Section Cited
CCR87464(f)(1)(c)

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(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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Licensee stated they will get an update prescription list from hospice and discharge all medications R1 is not taking. Licensee stated they will talk with hospice to see if R1 can be placed on a pill form of medication. A copy was provided to LPA during this visit. ***Deficiency cleared.
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This requirement was not met as evidence by: LPA observation and record review. The licensee did not comply with the section cited above in that R1's MARs shows 2 injectable medications were not provided to R1 (2x on 9/18/25). This poses an immediate health safety and or personal rights risk to residents in care.
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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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 04:06 PM - It Cannot Be Edited


Created By: Mary Garza On 09/18/2025 at 03:09 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: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
HSC
1569.185(b)(1)(F)

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1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (b) (1) In addition to fees set forth in subdivision (a), the department shall charge all of the following fees: (F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment.
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Licensee stated they will make payment for the annual and past due fees. A receipt will be sent to CCL as proof of correction by POC date.
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This requirement was not met as evidence by: records reviewed. The licensee did not comply with the section cited above in that the Licensee did not pay the current annual and past due fees associated to facility. This poses a potential health safety and or personal rights risk to residents in care.
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Type B
10/03/2025
Section Cited
CCR87628(a)

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(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.
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Licensee stated they will get written documentation from the physician and family member stating it is okay for the family to provide the injections to R1. Licensee stated they will provide documentation to CCL by POC date as proof of correction.
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This requirement was not met as evidence by: records reviewed. The licensee did not comply with the section cited above in that R1 is receiving injectable medications they are unable to provide to themselves and a medical professional is not providing. This poses a potential health safety and or personal rights risk to resients in care.
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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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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