107209007-2-19-2026-24-AS-KKAR-DRG226-20260219160012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209007
Report Date: 02/19/2026
Date Signed: 02/19/2026 04:02:11 PM

Document Has Been Signed on 02/19/2026 04:02 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:	FIVE STAR ASSISTED LIVING		FACILITY NUMBER:	107209007
ADMINISTRATOR/ DIRECTOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	5727 N. HAZEL AVE		TELEPHONE:	(818) 261-4887
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY: 6		CENSUS: 6	DATE:	02/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:19 AM
MET WITH:	Administrator Jasmine Oganyan		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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On 02/19/26 Licensing Program Analyst (LPA) K.Kaur arrived unannounced for an annual inspection visit. LPA was allowed entry by staff Maryann Castillo. LPA introduced self, explained reason for visit. Administrator Jasmine Oganyan was contacted and arrived a short while later.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, in good repair, with no passageway obstructions or fire hazards. Residents observed in common areas and in rooms. There was 1 resident on hospice. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 01/21/2026 and was fully charged. All common areas were properly furnished and well-lit throughout. LPA toured laundry area which appeared clean. Medications and first aid are kept locked in a closet next to laundry. Chemicals and cleaning supplies are locked in hallway closet and laundry room. Smoke Alarm and Carbon Monoxide detector tested and operational. All client bedrooms toured and observed to be adequately furnished. LPA observed one bedroom that is shared room and four with single occupancy. The exterior tour was conducted. Pool was observed gated and locked. The backyard was observed to have sufficient seating under covered Patio. Medication was reviewed. LPA observed PRN records missing orders. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/26/2026: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview conducted with Licensee. A copy of this report was discussed and provided to Licensee, whose signature on this form confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

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 02/19/2026 04:02 PM - It Cannot Be Edited

Created By: Kamaldeep Kaur On 02/19/2026 at 02:09 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: FIVE STAR ASSISTED LIVING	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(1)

This requirement is not met as evidenced by: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 residents records missing PRN medication statement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/19/2026
	Plan of Correction
1 2 3 4	Licensee agrees to obtain doctor statements for R1 regarding the resident’s ability to determine/ communicate need for Prescription PRN Medication and submit copies of documents to CCLD by due date.

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:

	Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC809 (FAS) - (06/04)

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