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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208832
Report Date: 04/09/2026
Date Signed: 04/09/2026 03:14:03 PM

Document Has Been Signed on 04/09/2026 03:14 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:COBBLE STONE RESIDENTIAL HOME CARE LLCFACILITY NUMBER:
157208832
ADMINISTRATOR/
DIRECTOR:		CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:9320 COBBLE MOUNTAIN ROADTELEPHONE:
(661) 397-0885
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 6DATE:
04/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:Administrator, Catherine ClarkTIME VISIT/
INSPECTION COMPLETED:
03:21 PM
NARRATIVE
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On 04/09/2026 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Care Giver, Zenaida Ganas explained reason for visit and was permitted entry into the facility. Administrator, Catherine Clark was contacted and arrived a short time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 5 of 6 resident was present during visit. 4 of 6 residents currently receiving hospice services.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors operate on a system and last serviced on 08/27/2024. Resident rooms observed to have the required furnishings and with adequate lighting. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: chemicals observed under the bathroom #2 sink, on the night stand in bedroom #2, in laundry room cabinet and in garage cabinet unlocked and accessible to residents in care. 2 of 2 resident files reviewed did not have the required documentation, 2 of 2 staff files did not have the required documentation. Disaster preparedness did not have a meeting location on facility sketch, 1 location outside the surrounding area and disaster drills are not being completed. Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct risk to the health, safety and/or personal rights of residents in care.

LPA requested the following documents to be submitted to CCL by 04/17/2026: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with Administrator, Catherine. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2026
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 04/09/2026 03:14 PM - It Cannot Be Edited


Created By: Mary Garza On 04/09/2026 at 02:44 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: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 in that LPA observed chemicals in bathroom #2 under sink unlocked and accessible. Chemical in laundry room cabinet observed unlocked and accessible. Chemicals in garage cupboard observed unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator stated they will lock all chemical or items as necessary. Training will be completed with all staff. In-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in that 2 of 2 personnel records reviewed did not have the required documents. S1 was missing health screening, job application, employee rights. S2 was missing documentation of fingerprint clearance, health screening, TB testing and employee rights.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator stated they will get copies of the required documents and provide to CCL by POC date as proof of correction.
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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/09/2026 03:14 PM - It Cannot Be Edited


Created By: Mary Garza On 04/09/2026 at 02:44 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: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in that 2 of 2 resident records did not have the required documentation. 2 of 2 medical assessments reviewed were over 1 year old. 2 of 2 files reviewed did not have a pre-admission appraisal. 2 of 2 files reviewed did not have a reappraisal completed within the last year. 2 of 2 files reviewed did not have a functional capabilties. 2 of 2 files reviewed did not have safeguarding for property/valuables.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator stated they will update the files with the required documenation and provide a copy to CCL by POC date as proof of correction.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in that 1 location shelter is not outside the immediate area. Facility sketch does not have an assembly point identified. Facility is not completing quarterly drills. Last fire disaster drill was last completed on 08/27/24. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator stated they will provide all staff training and quarterly drill. In-service sign in sheet and training material along with drills will be provided to CCL by POC date as proof of correction. Disaster plan to be updated and provided with annual documents.
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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


LIC809 (FAS) - (06/04)
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