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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209268
Report Date: 11/18/2025
Date Signed: 11/18/2025 05:49:36 PM

Document Has Been Signed on 11/18/2025 05:49 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:PRECIOUS LIFE RESIDENCES, LLCFACILITY NUMBER:
157209268
ADMINISTRATOR/
DIRECTOR:		CRISOSTOMO, PETROFACILITY TYPE:
740
ADDRESS:10414 BICHESTER COURTTELEPHONE:
(661) 472-9253
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
11/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Licensee Susan Blanza TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 11/18/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduced self, stated the purpose of the visit and met staff Kaela Martinez. Licensee/ Administrator (L1) Susan Blanza was called and arrived shortly. LPA toured facility with Licensee. All five residents were present during inspection.

The facility was observed to be at a comfortable temperature, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature was maintained at 38 degrees F and freezer temperature maintained at -2 degrees F. Fire extinguisher was observed with a service date of: 08/09/24. Fire drills last completed: 09/10/25.

LPA and L1 observed medications medication cabinet unlock. Medications were observed under dining room counter unlocked. MARs were reviewed and medications were checked. Knives were observed locked kitchen drawers to the right of the stove. Cleaning chemicals were observed unlocked in the dining room, in the laundry room, in the garage, in the garage cabinet, in the master bathroom, and outside in the patio. All bedrooms were observed to have the required furnishings and adequate lighting. Extra linens and towels were observed. The bathrooms were toured. Bathrooms were observed with non-skid mats and grab bars. Hot water temperature was tested at 106 degrees F in bathroom 1 and at 106.3 degree F in master bathroom.

Outside of the facility toured. The side gate observed free of debris. Adequate outdoor seating is observed to be available for residents. Carbon monoxide and smoke detectors were tested and observed to be operational. Half of client’s were reviewed to have all the required documents.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:12 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, S1 is not fingerprinted cleared and not associated to facility was providing resident care and supervision, which poses an immediate risk to the health and safety of the residents.
POC Due Date: 11/19/2025
Plan of Correction
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S1 left the facility during visit. S1 is not permitted back until fingerprinted cleared and associated to the facility.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 Licensee observed residents’ medications stored and unlock in the medication cabinet, medication on nightstand in room 4, and medications for former residents under dining room counter, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee shall ensure all medications are locked and inaccessible to residents by POC due date 11/19/25.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:15 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations, records reviewed, and interviews conducted, L1 administered R1’s Stimulant laxative medication on 11/18/25 in the morning, and R1’s Fentanyl patch was applied on 11/09/25 and did not record in the resident’s MARs, which poses/posed a potential health and safety risk for the person in care.
POC Due Date: 11/19/2025
Plan of Correction
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L1 will be retrained in-service training on proper administering medication and documentation. Licensee will submit proof of retraining in-service training to CCL by POC due date 11/19/25.
Type A
Section Cited
CCR
87309(a)
87309(a)…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.

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 L1 observed knives stored in kitchen drawer, chemicals and cleaning solution unlock throughout the facility and tools were unlock in the garage cabinet, accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee immediately locked knives, chemicals and cleaning solution. POC cleared during visit.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:17 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 08/09/24, which poses an immediate health and safety risk to the residents.
POC Due Date: 11/19/2025
Plan of Correction
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Fire extinguisher shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 11/19/25.
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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S2 do have current First Aid/ CPR certification, this poses an immediately health and safety risk for the residents in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee shall ensure that staff have current First Aid/ CPR certification. Proof of S2 First Aid/ CPR certification is to be submitted to the Fresno CCL by 11/19/25.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:18 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

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’s file, whose currently receiving hospice care with no hospice care plan on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Licensee will obtain R1’s current hospice care plan and submit it to Fresno CCL by POC due date 11/24/25.
Type B
Section Cited
CCR
87506(b)(17)
87506 (b)(17) Documents and information required…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, all residents’ files were reviewed. A complete appraisal (Lic 603) and was not observed in R1 and R5 files. A complete Needs and Services plan (Lic 625) was not observed in R3, R4and R5’s files. Medical Consent form (Lic 627C) was not observed in R2, R3, and R5’s files. R5’s file was observed with no current physician report (Lic 602A), which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 12/01/2025
Plan of Correction
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Licensee shall ensure that all residents have the required records on file. Completed Lic 603 for R1 and R5, completed Lic 625 for R2, R3, R4 and R5, Lic 625C for R2, R3, and R5, and Lic 602A for R5 will be completed and submitted the Fresno CCL office by POC due date 12/01/25.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:19 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted, observation and records reviewed, R4 uses a half rail bed. There is no doctor’s order for ½ rail bed for R4, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 11/24/2025
Plan of Correction
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Licensee state will obtain doctor’s order for ½ rail bed. Doctor’s order will be submitted to the Fresno CCL by POC due date 11/24/25.
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, R1 whose receiving hospice care and R2 whose not receiving hospice care were observed with full rail bed, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 11/24/2025
Plan of Correction
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Full bed rails are prohibited. If doctor indicates the need for R1 to have full rails bed, order will be obtain and submitted to Fresno CCL by POC due date. R1 and R2 full rails shall be removed by POC due date 11/24/25.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:20 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 (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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4
Based on observation, LPA and L1 toured the facility and observed side backyard fence boards broken, spider webs were observed around the outside of the facility patio and walls, live cockroach was observed in kitchen drawer, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 11/24/2025
Plan of Correction
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The facility shall be in good repair, clean, and sanitary by POC due date. Proof of repair of the backyard fence board, proof of spider webs cleaned, and pest control services schedule for cockroach will be submitted to the Fresno CCL by POC due date 11/24/25.
Section Cited
Deficient Practice Statement
1
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268
VISIT DATE: 11/18/2025
NARRATIVE
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A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421IM.

Technical Support Program (TSP) assistance was offered to Licensee and was accepted. The department will complete TSP referral.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/24/25. Forms requested: Lic 308, Lic 500, Lic 610E, and current Administrator certificate. A copy of this report and appeal was provided to 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: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 11/18/2025 05:49 PM - It Cannot Be Edited


Created By: Mai Yang On 11/18/2025 at 04:52 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 (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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA and L1 observed wood stick on the bottom of the exit sliding door blocking and preventing sliding door to open. LPA was informed by L1 and S2 that the wood stick is to prevent anyone from coming inside at night, which an immediate health and safety risk which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Administrator immediately removed metal lever rod. POC cleared during visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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