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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206846
Report Date: 02/05/2026
Date Signed: 02/06/2026 09:30:31 AM

Document Has Been Signed on 02/06/2026 09:30 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:TEHACHAPI MANORFACILITY NUMBER:
157206846
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, LORENAFACILITY TYPE:
740
ADDRESS:20400 OAK KNOLL DR.TELEPHONE:
(661) 822-7885
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY: 6CENSUS: 4DATE:
02/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Licensee Lorena Rodriguez TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 02/20/25, Licensing Program Analysts (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Cristian Chavez. Licensee Lorena Rodriguez was called and arrived shortly with staff Alejandra Gaitan. All four resident was present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Outside observed free of debris. Outdoor seatings observed available for residents. Fire extinguisher was observed with a purchase date of 01/03/26. Last fire drill completed on 12/2025. Temperature maintained for refrigerator at 34 degrees F and freezer maintained at 0 degrees F. An adequate supply of perishable and non-perishable food was observed. Medications observed kept locked in laundry room. Cleaning supplies and chemicals stored and locked in laundry room. All bedrooms were observed to have required furnishings and with adequate lighting. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 105.2 hall bathroom, shared bathroom in room 2 and room 3 tested at 110.6 and 111.1 degrees in shared bathroom, and shared bathroom in room 4 and room 5 tested 109.6 and 110.7 degrees. Smoke detectors were tested and observed to be operational. All residents’ and a sample of staff files were reviewed.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA received copies of Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to the Licensee, 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: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2026
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 02/06/2026 09:30 AM - It Cannot Be Edited


Created By: Mai Yang On 02/05/2026 at 01:56 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: TEHACHAPI MANOR
FACILITY NUMBER: 157206846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews, 3 out of 3 staff do not have current CPR certification, this poses an immediately health and safety risk for the residents in care.
POC Due Date: 02/06/2026
Plan of Correction
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Licensee shall ensure that staff have current CPR certification. Proof of staff CPR certification is to be submitted to the Fresno CCL by 02/06/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/06/2026 09:30 AM - It Cannot Be Edited


Created By: Mai Yang On 02/05/2026 at 01:58 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: TEHACHAPI MANOR
FACILITY NUMBER: 157206846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when LPA reviewed R1 whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensee will obtain R1 current hospice care plan and submit it to Fresno CCL by POC due date 02/18/26.
Type B
Section Cited
CCR
87412(a)(11)
87412(a)(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews conducted, S1 do not have a health screening (Lic 503) completed, this poses a potential health and safety risk for the residents in care.
POC Due Date: 02/25/2026
Plan of Correction
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Licensee stated S1 will complete Lic 503 by POC due date. S1’s Lic 503 will be submitted by POC due date 02/25/26.
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: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
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