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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209483
Report Date: 01/14/2026
Date Signed: 01/27/2026 09:42:34 AM

Document Has Been Signed on 01/27/2026 09:42 AM - 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:CLOSE TO HOME RESIDENTIAL CAREFACILITY NUMBER:
107209483
ADMINISTRATOR/
DIRECTOR:		AMBRIZ, EMILYFACILITY TYPE:
740
ADDRESS:5852 E BURNS AVETELEPHONE:
(559) 708-8822
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 5DATE:
01/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with House Lead Janay Gonzalez.


Facility is licensed for 6 residents and has a current census of 5. There is 1 resident on hospice and 2 on health care. Water temperature was checked in the kitchen which read at 105 degrees Fahrenheit and in the common bathroom which read at 105.2 degrees Fahrenheit. Fire Extinguishers still have charge, but need to be serviced. Licensee will follow-up. Smoke and carbon monoxide detectors were tested and in working order.


Emily Ambriz Administrator's Certification expires November 4, 2026. Staff files were reviewed, training needs to be updated and conducted for hoyer lift & oxygen. Resident files were reviewed. Resident files are missing hospice care plans and home health care plans. Facility did not previously obtain prior approval to have a resident with oxygen. Facility does not have a correct log for disaster drills that are conducted quarterly (facility conducts drills monthly). First aid kit on site and complete. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications. LPA reviewed resident's centrally stored medication log which is not complete or current for residents.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2026
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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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: CLOSE TO HOME RESIDENTIAL CARE
FACILITY NUMBER: 107209483
VISIT DATE: 01/14/2026
NARRATIVE
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LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean, properly furnished, with adequate lighting, and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

Licensee will provided proof of liability insurance, a picture of fixed light switch in common bathroom, and changed lock for additional space connected to the garage. Due by 1/16/2026


Exit interview conducted a copy of this report LIC809, LIC809D, and appeal rights were provided to House Lead Janay Gonzalez.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/27/2026 09:42 AM - It Cannot Be Edited


Created By: Brianna Miranda On 01/14/2026 at 01:44 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: CLOSE TO HOME RESIDENTIAL CARE
FACILITY NUMBER: 107209483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(c)(1)
87618 Oxygen Administration - Gas and Liquid
(c) The licensee shall be permitted to accept or retain a resident who requires the use of liquid oxygen under the following circumstances:
(1) The licensee obtains prior approval from the licensing agency.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee will submit an exception request for R1.
Type A
Section Cited
CCR
87465(a)(6)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed R2 & R3's centrally stored medication logs which were no complete.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee will provide a timeframe in writing regarding centrally stored medication logs to be completed and correct.
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: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/27/2026 09:42 AM - It Cannot Be Edited


Created By: Brianna Miranda On 01/14/2026 at 01:50 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: CLOSE TO HOME RESIDENTIAL CARE
FACILITY NUMBER: 107209483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(b)(4)
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:
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe hospice care plan on file for resident currently on hospice.
POC Due Date: 01/21/2026
Plan of Correction
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Licensee will provide a copy to the Dept by POC due date 1/21/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/27/2026 09:42 AM - It Cannot Be Edited


Created By: Brianna Miranda On 01/14/2026 at 01:53 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: CLOSE TO HOME RESIDENTIAL CARE
FACILITY NUMBER: 107209483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(h)
87411 Personnel Requirements - General
(h) All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe training specific to using the hoyer lift or in regards to resident's oxygen use.
POC Due Date: 01/21/2026
Plan of Correction
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Licensee will conduct training and provide verification of training to the Dept by POC due date.
Type B
Section Cited
CCR
87609(A)(B)(C)
87609 Allowable Health Conditions and the Use of Home Health Agencies
(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).
(A) The written agreement shall reflect the services, frequency and duration of care.
(B) The written agreement shall include day and evening contact information for the home health agency, and the method of communication between the agency and the facility, which may include verbal contact, electronic mail, or logbook.
(C) The written agreement shall be signed by the licensee or licensee representative, and representative of the home health agency, and placed in the resident’s file.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe Home Health Plans to be in resident files.
POC Due Date: 01/21/2026
Plan of Correction
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Licensee will obtain current Home Health Care plans for residents to the Dept by POC 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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