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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208889
Report Date: 07/11/2025
Date Signed: 07/11/2025 04:05:09 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
04/10/2025 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20250410163831
FACILITY NAME:LAVERNE SENIOR CAREHOMEFACILITY NUMBER:
107208889
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:3194 LAVERNE AVETELEPHONE:
(559) 292-0074
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lisa Pua, Assistant AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility does not have proper fire clearance
INVESTIGATION FINDINGS:
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On 07/11/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced subsequent
complaint investigation and met with Assistant Administrator Lisa Pua.

During the course of the investigation, the Department conducted interviews, reviewed records, and toured the facility. The facility has no fire clearance for bedridden resident and has admitted R1 a bedridden resident to the facility.

Based on observation, interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 is being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator Assistant, whose signature confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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-20250410163831
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: LAVERNE SENIOR CAREHOME
FACILITY NUMBER: 107208889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2025
Section Cited
CCR
87202(a)(2)
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87202 (a)(2) 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:
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Facility is not fire cleared for bedridden residents therefore cannot obtain bedridden residents to the facility. Licensee will provide a written statement detailing steps the facility will take to ensure to meet regulations by POC due date 07/12/25.
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Based on observation and records reviewed, R1 is bedridden and resides at the facility with no fire clearance for bedridden, which poses/posed an immediate health and safety and personal rights risk to the resident 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
04/10/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250410163831

FACILITY NAME:LAVERNE SENIOR CAREHOMEFACILITY NUMBER:
107208889
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:3194 LAVERNE AVETELEPHONE:
(559) 292-0074
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lisa Pua, Assistant AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff violating residents personal rights
Facility staff not meeting residents incontinence needs
Facility served illegal eviction
Staff administering medications not prescribed
Staff hit resident
INVESTIGATION FINDINGS:
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On 07/11/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Assistant Administrator Lisa Pua.

During the course of the investigation, the department reviewed R1’s records and facility records, conducted interviews, and toured the facility. R1 has possession and access to R1’s cellphone. R1’s briefing is being changed by staff. R1’s room has no odor smell. An eviction notice was provided to R1 on 04/08/25. Based on records reviewed and observed, it is undetermined staff is administered medications not prescribed and staff hit resident. Therefore, the preponderance of evidence standard has not been met, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this report confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3