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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 01/06/2026
Date Signed: 01/13/2026 01:25:30 PM

Document Has Been Signed on 01/13/2026 01:25 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:
01/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee, Yanina GarciaTIME VISIT/
INSPECTION COMPLETED:
06:16 PM
NARRATIVE
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On 01/06/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete an unannounced annual visit. LPA met with Licensee, Yanina Garcia, explained reason for visit and was permitted entry into the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 5 resident was present during visit. 3 residents receiving hospice services and 1 resident receiving home health services at time of visit.

Pathways and doors were clear and free from obstruction inside facility. 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. Fire extinguisher last purchased on 1/3/26 and observed fully charged. Last fire drill on conducted on 07/30/25. Resident rooms observed to have the required furnishings and with adequate lighting. Chemicals and medications were located in locked closets/cupboards. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: Facility does not have an active administrator in place. 2 of 5 residents are bedridden and facility does not have an appropriate fire clearance. 3 of 5 residents are receiving hospice services and the facility has an hospice wavier for 2 residents. Outside freezer observed to be leaking water and measured at 13 degrees F. Oxygen tanks observed unsecured in hallway closet off kitchen. Freezer in kitchen measured at 8 degrees F. Interviews with staff and residents disclosed staff is conducting testing and injections for restricted health condition. 2 of 5 residents have a Homrestricted health condition and an exception request has not been submitted.

CONT...

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
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 9
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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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: NINA'S HOME
FACILITY NUMBER: 107207121
VISIT DATE: 01/06/2026
NARRATIVE
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CONT...

Water temperature tested at 128.8 degrees F. False statement(s) made by S2 and Licensee to LPA regarding R2's testing/injections being completed by a family member and by S2 regarding home health services being provided for R1. Personal rights, nondiscrimination notice and complaint information is not posted at the facility. 1 of 3 resident records reviewed did not have an updated medical assessment within the last year. Disaster Preparedness Plan- assembly points are not identified on the facility sketch. One shelter location is not outside the immediate area. Fire drills are not being conducted quarterly. 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 direct risk to the health, safety and/or personal rights of residents in care. *****Immediate civil penalty in the amount of $500 assessed for fire clearance deficiency.*****

LPA requested the following documents to be submitted to CCL by 01/16/2026: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with Licensee, Yanina, Administrator, Shemeka Turner and Caregiver, Marc Fuentes. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, civil penalties and appeal rights were discussed and provided to Licensee.

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

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 04:03 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

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 the facility administrator on record, Leticia Rodriguez, was no longer working with the facility as of 10/15/2024. On 12/30/24 Licensee submitted a request, to change administraor to Phouen Marez. Licensee was notified the request was missing a letter appointing new administrator, LIC 308 and LIC 9182. Effective 9/9/25, Phouen Marez, was no longer working with the facility. A new request was submitted to change administrator on 12/31/25 to Shemeka Turner. However, the request is incomplete and missing a resume and a letter appointing the new administrator. From 9/9/25 to 12/31/25 the facility has not had an active administrator. This poses an immediate health, safety and or personal rights risk to residents in care.
POC Due Date: 01/07/2026
Plan of Correction
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Administrator stated they will supply the proper paperwork. Paperwork will be submitted to CCL by POC date as proof of correction.
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 5 residents were observed with a trapeze assistive device over their beds. Facility does not have a fire clearance for bedridden residents. This poses an immediate health, safety or personal rights risk to persons in care. *****An immediate civil penalty in the amount of $500 is assessed.****
POC Due Date: 01/07/2026
Plan of Correction
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Administrator stated they will subit a corrected LIC 200 to CCL by POC date as proof of correction.
*****An immediate civil penalty in the amount of $500 is assessed. *****
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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 04:03 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the water temperature measured at 128.8 degrees F. This poses a potential health safety and or personal rights risk to residents in care.
POC Due Date: 01/16/2026
Plan of Correction
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Water heater immediately turned down. Administrator stated they will complete a water temperature log. Temperature will be tested 2xs daily in 2 separate locations for 2 weeks. Water log will be submitted to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Personal rights, nondiscrimination notice and complaint information is not posted at the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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Administrator stated they will post all required postings. Pictures will be taken and sent 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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 04:03 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, the licensee did not comply with the section cited above in 1 of 3 resident files was observed medical assessment with a date of 6/6/24 and not completed within the last year. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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Administrator stated they will have updated medical assessments completed for residents and submit to CCL by POC date as proof of correction.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 the emergency disaster plan did not have assembly points identified on the facility sketch. One shelter location not outside the immediate area. Disaster drills are not being conducted quarterly. This poses which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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Administrator stated they will update the plan and facility sketch 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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 05:09 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87207
87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above in that False statement(s) made by S2 and Licensee to LPA regarding R2's testing/injections being completed by a family member and by S2 regarding home health services being provided for R1. This poses an immediate health safety and or personal rights risk to residents in care.
POC Due Date: 01/07/2026
Plan of Correction
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A plan of correction in writting will be submitted to CCL by POC date to include how this deficiency will be corrected.
Type A
Section Cited
CCR
87628(a)
87628 Diabetes

(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Base on interviews conducted and records reviewed. The licensee did not comply with the section cited above in that R2’s medicatin log showed staff are providing testing/injections. Interview with R2 indicated staff are assisting with both testing and injections. This poses an immediate health safety and or personal rights risk to resident(s) in care.
POC Due Date: 01/07/2026
Plan of Correction
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Administrator stated they will provide a plan of correction in writting to include how they will address getting testing and injections completed for R2. This will be submitted to CCL by POC date. Once plan is in place, verification will be sent to CCL no later than 1/16/2026.
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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 05:26 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(E)
87618 Oxygen Administration - Gas and Liquid

(b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in 3 of 6 oxygen tanks observed in closet off kitchen were unsecured. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2026
Plan of Correction
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2
3
4
Administrator stated they will contact the oxygen company to come and pick up the tanks or provide stands. Receipt will be provided to CCL by POC date as proof of correction.
Type A
Section Cited
CCR
87204(a)
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewed, the licensee did not comply with the section cited above in 3 of 5 residents are receiving hospice services. The facility has a hospice wavier for 2 residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2026
Plan of Correction
1
2
3
4
Administrator stated they will provide a plan of correction in writiing to include requesting an exception for the last resident accepted into the facility.
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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 01/13/2026 01:25 PM - It Cannot Be Edited


Created By: Mary Garza On 01/06/2026 at 05:30 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: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(21)
87555 General Food Service Requirements

(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that the freezer in the garage was leaking water and measured at 13 degrees F and the freezer inside kitchen measured at 8 degrees F. This posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
1
2
3
4
Freezer was turned down immediately. A plan of correction in writting will be submitted to CCL by 1/6/25. Correction will be completed by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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