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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209233
Report Date: 11/14/2025
Date Signed: 11/14/2025 02:09:12 PM

Document Has Been Signed on 11/14/2025 02:09 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:LA CASA DELLA NONNAFACILITY NUMBER:
107209233
ADMINISTRATOR/
DIRECTOR:		MAREZ, PHOEUNFACILITY TYPE:
740
ADDRESS:2570 W ALLUVIAL AVENUETELEPHONE:
(559) 400-6700
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
11/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Direct Care Staff, MariaTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
NARRATIVE
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On 11/14/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced health and safety check on residents in care. This visit is being conducted due to the facility being on increased monitoring. LPA met with Direct Care Staff, Maria Avendano-Nicolas, explained reason for visit and was permitted entry into the facility. House Manager, Hilda Deroux was contacted and arrived some time later. During visit LPA completed a tour of the facility and observed residents in care in dining area and in rooms. There are currently 2 residents receiving hospice services. 1 resident is bedridden at this time.

On 9/9/25 the Department received notification the Administrator, Phoeun Marez was no longer acting as the Administrator at the facility. Licensee was notified on 9/26/25 a complete packet had not been received naming a new Administrator. At this time the facility does not have an active Administrator.

During an NCC on 2/6/25, Licensee was notified their hospice wavier was being decreased to 1 and could not accept any new residents without an exception. Interviews conducted and records reviewed identified there are currently 2 residents on hospice. Both do not have a current hospice care plan. 1 of 2 was admitted on 11/7/25. The Department has not received an exception request for this resident.

LPA observed hallway fire door propped open with a wedge door stop. Record review identified S1 was not fingerprint cleared.

Deficiencies cited per California Code of Regulations, Title 22. Deficiencies cited on attached 809D. If not corrected, these deficiencies will have a direct impact to residents in care.

Exit interview conducted with House Manager, Hilda. A plan of correction was developed by Licensee via telephone and House Manager, Hilda and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
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 11/14/2025 02:09 PM - It Cannot Be Edited


Created By: Mary Garza On 11/14/2025 at 12:19 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: LA CASA DELLA NONNA
FACILITY NUMBER: 107209233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2025
Section Cited
CCR
87202(a)

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Staff immediately removed and closed the door. House Manager stated they will provide training to all staff. An in-service sign in sheet and training material will be provided to CCL as proof of correction.
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This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that the hallway fire door was being propped open with a wedge door stop. This poses an immediate health, safety and or personal rights risk to residents in care.
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Type A
11/17/2025
Section Cited
CCR87405(a)

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(a) All facilities shall have a qualified and currently certified administrator...
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Licensee stated they will provide a complete packet and submit to CCL for the new Administrator by POC date.
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This requirement was not met as evidence by: record review and interviews conducted. The licensee did not comply with the section cited above in that the facility does not have an active administrator since 9/9/25. 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: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2025 02:09 PM - It Cannot Be Edited


Created By: Mary Garza On 11/14/2025 at 12:32 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: LA CASA DELLA NONNA
FACILITY NUMBER: 107209233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2025
Section Cited
CCR
1569.73(d)

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1569.73 Terminally ill residents; or terminally ill persons to be accepted as a resident; transferring hospice care and waivers; resident care and supervision (a) Notwithstanding Section 1569.72 or any other provision of law, a residential care facility for the elderly may obtain a waiver...(d) Nothing in this section is intended to expand the scope of care and supervision for a residential care facility for the elderly as defined in this act, nor shall a facility be required to alter or extend its license in order to retain a terminally ill resident or allow a terminally ill person to become a resident of the facility as authorized by this section.
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Licensee stated they will submit an exception request to CCL for last resident accepted into the facility on hospice.
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This requirement was not met as evidence by: record review and interviews conducted. The licensee did not comply with the section cited above in that the facility has a hospice wavier for 1resident and currently has 2 residents on hospice. This poses an immediate health, safety and or personal rights risk to residents in care.
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Type A
11/17/2025
Section Cited
CCR87633(a)(4)

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87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness...prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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Licensee stated they will reach out to hospice agency to get care plan for resident receiving hospice services and send a copy to CCL by POC date as proof of correction.
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This requirement was not met as evidence by: record review. The licensee did not comply with the section cited above in that 2 of 2 residents receiving hospice services did not have a care plan. 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: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2025 02:09 PM - It Cannot Be Edited


Created By: Mary Garza On 11/14/2025 at 12:51 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: LA CASA DELLA NONNA
FACILITY NUMBER: 107209233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2025
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department.
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Staff was immediately removed from the facility and schedule. Staff was sent to be fingerprint cleared. Licensee stated they understand staff can not return to the facility or be on the schedule until they are cleared to return.
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This requirement was not met as evidence by:LPA observations and records review. The licensee did not comply with the section cited above in that S1 was observed to be working with residents in care and to not have a fingerprint clearance. 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: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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