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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209480
Report Date: 10/27/2025
Date Signed: 10/27/2025 05:27:36 PM

Document Has Been Signed on 10/27/2025 05:27 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:STONEHAVEN SENIOR LIVINGFACILITY NUMBER:
107209480
ADMINISTRATOR/
DIRECTOR:		SALOW, DONALDFACILITY TYPE:
740
ADDRESS:1717 SOUTH WINERY AVENUETELEPHONE:
(659) 251-8417
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 116CENSUS: 93DATE:
10/27/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 AM
MET WITH:Radhika Jawa Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 10/27/2025 LPAs B. Miranda & S. Doucette arrived to the facility unannounced to conduct a case management visit. LPAs initially met with Radhika Jawa Assistant Administrator, and Consultant Jaycee Sanderson arrived later.

During the unannounced visit LPAs observed the following:

LPAs reviewed staff roster and cleared staff on licensing system. LPAs observed staff files, schedule, and conducted interviews which verified some staff on duty to not have proper background clearance. Jaycee sent uncleared staff home and informed staff not on duty with uncleared background clearances to not return to work until background clearance is completed.

LPAs observed some residents without call buttons and another resident with call button not working. LPAs were informed that the call button board only holds 6-7 calls and then will stop sounding if the board is full. LPA also observed R5’s call button in the bathroom to not be in working order. Jaycee later explained the system for the bathroom call lights was unplugged. Jaycee plug in system and placed a notice to not unplug.

LPA observed R5’s bathroom to have dead cockroaches and debris.

LPA observed R4’s file and conducted interviews. Documentation shows on 10/5/2025 R4 fell and hit his head. A timely report was found to not be made to licensing. The facility failed to call 9-1-1 and seek medical attention, this did not allow R4 to directly refuse medical services to emergency services or to be properly assessed.

Under California Title 22 citations will be issued.

Exit interview was conducted with Radhika Jawa, a copy of this report LIC809, LIC809-D, and appeal rights were provided to Radhika Jawa Assistant Administrator.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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 5
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 10/27/2025 05:27 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/27/2025 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: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 107209480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2025
Section Cited
CCR
87355(e)(2)

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(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 or
This requirement is not met as evidenced by:
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Jaycee had all staff without proper background clearance to leave the facility until background clearance has been completed.
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Based on record review, the licensee did not ensure fingerprint clearance has been obtained for all staff members on and off duty, which poses an immediate Health, Safety or Personal Rights risk to persons in care.
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Type A
10/28/2025
Section Cited
CCR87465(g)

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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

This requirement is not met as evidenced by:
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Facility will be speaking with family regarding calling emergency services for residents who fall and hit their head.
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Based on observation, interview, and record review, the licensee failed to call for 9-1-1 after R4 fell and hit their head, which poses an immediate Health, Safety or Personal Rights risk to persons 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2025 05:27 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/27/2025 at 04:19 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: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 107209480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
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Jaycee stated reports will be sent for any incidents that happen at the facility.
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Based on observation, interviews, and record review, the licensee failed to report R4's fall in a timely manner to CCLD, which poses a potential Health, Safety, or Personal Rights risk to residents in care.
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Type B
11/07/2025
Section Cited
CCR87303(i)(1)(B)

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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
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Jaycee will have a call button board added to each wing.
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Based on observation, interviews, and record review, the licensee failed to have a proper signal system within the facility. LPA tested call buttons which did not alarm due to call button board being full. The call button board hold only 6 calls, this poses a potential Health, Safety, 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2025 05:27 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/27/2025 at 04:34 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: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 107209480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Jaycee will have R5's room checked in and cleaned.
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Based on observation & interviews the licensee failed to maintain R5's bathroom which has dead cockroaches and debris, this poses a potential Health, Safety, 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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