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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202411
Report Date: 02/17/2026
Date Signed: 02/17/2026 02:36:06 PM

Document Has Been Signed on 02/17/2026 02:36 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:BLUE PEARL HOME CARE IIFACILITY NUMBER:
157202411
ADMINISTRATOR/
DIRECTOR:		CRISOSTOMO, PETROFACILITY TYPE:
740
ADDRESS:10018 SAINT ALBANS AVENUETELEPHONE:
(661) 412-8164
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 4DATE:
02/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Jelyn Pino, staffTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 02/17/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with staff (S1) Jelyn Pino. Licensee/Administrator (L1) Petro Crisostomo was called and stated unavailable to attend meeting. Licensee authorized staff to sign and receive report. LPA toured facility with S1. All four residents were present upon LPA arrival. One resident left for the doctor’s appointment shortly after LPA arrival. Resident observed in common area.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Staff medications were observed unlocked in staff bedroom. All residents and a sample of staff files were reviewed. Medications were checked and observed kept locked in the kitchen shelf. An adequate supply of perishable and non-perishable food was observed. Knives and sharps were observed locked in kitchen drawers. Freezer temperature was observed maintained at 0 and refrigerator maintained at 40 degrees F. Fire extinguisher was observed with a purchase date of: 03/05/25. Last fire drill completed on 01/1/26. First Aid kit observed with all required items. Cleaning solutions observed locked in laundry cabinet. A chemical bottle and staff medication bottle were observed unlocked in the garage. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. R3 bed was observed with full bed rails up. All bathrooms are observed with securely fastened grab bars and non-skid mats. Hot water temperature was tested 117.4 degrees F. in master bathroom and 112.6 degrees F in bathroom. Outside of facility toured and observed free of debris. Side gate was self-closing and self-latching. Outdoor seating observed is available for residents. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents’ MARS were reviewed, and medications were checked.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2026
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 7
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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411
VISIT DATE: 02/17/2026
NARRATIVE
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Technical Support Program (TSP) assistance was offered to staff. Staff will inform Licensee and will make a decision and reach out the department regarding acceptance.

A deficiency and a civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 421IM.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 02/23/26. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee/Administrator, whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2026 02:36 PM - It Cannot Be Edited


Created By: Mai Yang On 02/17/2026 at 01:57 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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and S1 observed at 11:22AM, S2’s medications unlocked in staff room. At 11:32AM, LPA and S1 observed laundry liquid fabric softener and S2’s medication bottle unlocked in the garage, accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Staff immediately locked staff medications and chemical bottle. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted, observation and records reviewed, R1’s medications Vitamin D3 was not administered on 02/17/26 in the morning. R1’s medication Mucus Relief was not administered on 02/16/26 in the evening and not administered on 02/17/26 in the morning. 2 out 11 of R1’s medications were not administered as prescribed by physician, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include medication audit, reviewing medication, and training to Fresno CCL office by POC due date 02/18/26.

Licensee shall have all staff in-service training on medications regulations. Licensee will submit documentation of training topics including training date, training materials, training instructor name, and staff attendance rooster to the Fresno CCL office by 3/02/26.
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:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2026 02:36 PM - It Cannot Be Edited


Created By: Mai Yang On 02/17/2026 at 01:59 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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R2 is not hospice care and is using a hospital bed with full rail with doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 02/18/2026
Plan of Correction
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Staff removed full bed rails during inspection. POC cleared during visit.
Type B
Section Cited
CCR
87612(a)(2)
87612 (a)(2) The licensee may provide care for residents who have any of the following restricted health conditions, (2) Catheter care as specified in Section 87623.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted, observation, and records reviewed, R1 has a restricted health conditions with no restricted health condition care plan on file or in placed, poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 03/06/2026
Plan of Correction
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The facility will obtain Restricted Health Condition care plan Foley Catheter for R1 that includes staff training if required staff care by POC due date. Care plan and staff trainings will be submitted to the Fresno CCL by POC due date 03/06/25.
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:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2026


LIC809 (FAS) - (06/04)
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