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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208828
Report Date: 03/02/2026
Date Signed: 03/02/2026 06:29:25 PM

Document Has Been Signed on 03/02/2026 06:29 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:A GOLDEN HEART FAMILY CAREFACILITY NUMBER:
157208828
ADMINISTRATOR/
DIRECTOR:		LIGON, MICHELLEFACILITY TYPE:
740
ADDRESS:13402 GIRO DRIVETELEPHONE:
(661) 368-2333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 6DATE:
03/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:49 AM
MET WITH:Administrator Michelle LigonTIME VISIT/
INSPECTION COMPLETED:
07:00 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 Administrator Michelle Ligon.

Facility is licensed for 6 residents and has a current census of 6. There are 3 residents on hospice. Water temperature was checked in the kitchen which read at 111.2 degrees Fahrenheit and the common bathroom which read at 107.4 degrees Fahrenheit. Fire Extinguisher was serviced February 26, 2026 and is within the safety regulation period. Smoke and carbon monoxide detectors were tested and in working order.

Michelle Ligon Administrator's Certification is expired and currently pending. Jocelyn Ligon has a current Administrator's certificate. Staff files were reviewed S1 & S2 do not have the required annual training hours. Resident files were reviewed. Facility provided a log for disaster drills that are conducted monthly. First aid kit on site and complete. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications, but medication was also stored in separate containers in unlocked hutch behind kitchen table.
LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, 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.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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 03/02/2026 06:29 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/02/2026 at 03:48 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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

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 observed the emergency exit through the garage to not be obstruction free.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee will clear pathway for emergency exit. Picture verificaiton will be sent to the Dept by POC due date.
Type A
Section Cited
CCR
87309(b)
(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.

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. 2 (R3 & R4) of the 6 residents are listed as being at risk if hygiene products are accessible to residents.
POC Due Date: 03/03/2026
Plan of Correction
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Administrator will follow-up with hospice and provide new information to the Dept. Verification will be sent 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: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/02/2026 06:29 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/02/2026 at 03:48 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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 observed medication being placed in containers to be given at a later time. S1 stated it is to make it easier when giving medications.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee will not longer transfer medications to other containers. Verification will be sent to the Dept by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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 observed medication in unlocked cabinet behind the kitchen table.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee will place lock on cabinet door. Verification will be provided 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: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/02/2026 06:29 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/02/2026 at 03:48 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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(A)
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at 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 spoke with Administrator Michelle who stated there was no written report made to the local fire department regarding the oxygen equipment being used at the house.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee will report to the local fire dept and provide a copy to licensing. Verification will be sent to the Dept by POC due date.
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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/02/2026 06:29 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/02/2026 at 03:48 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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 reviewed files and only found current training to equal a total of 9 hours for S2 & S3.
POC Due Date: 03/20/2026
Plan of Correction
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Licensee will will completed training with staff and provide verification of training. Verification will be sent to the Dept by POC due date.
Type B
Section Cited
CCR
87303(a)
(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:
Deficient Practice Statement
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Based on observation & interview, 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 observed torn screens on the side of the house, torn screen door from the Master Bedroom, water damage under the kitchen sink, debris inside of the kitchen oven.
POC Due Date: 03/13/2026
Plan of Correction
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Licensee will fix the items listed above and verificaiton will be sent to the Dept. Verification will be provided 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: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/02/2026 06:29 PM - It Cannot Be Edited


Created By: Brianna Miranda On 03/02/2026 at 03:48 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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(d)
Hospice Care for Terminally Ill Residents
(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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2
3
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Licensee will provide current hospice care plan by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
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: A GOLDEN HEART FAMILY CARE
FACILITY NUMBER: 157208828
VISIT DATE: 03/02/2026
NARRATIVE
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LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, 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.


The following deficiencies were observed and cited during today's inspection per California Code of Regulations, Title 22.
  • R3 & R4 physician reports state they are at risk if hygiene products that are accessible to them.
  • LPA observed medication in unlocked cabinet behind the kitchen table.
  • LPA observed medication being placed in containers to be given at a later time.
  • LPA did not observe training for oxygen.
  • Staff documented training totaled 9 hours.
  • LPA observed emergency exit through garage to be partially obstructed.
  • LPA observed torn screens on the side of the house, torn screen door from the Master Bedroom, water damage under the kitchen sink, debris inside of the kitchen oven.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

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

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
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