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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209363
Report Date: 10/24/2025
Date Signed: 10/24/2025 01:48:21 PM

Document Has Been Signed on 10/24/2025 01:48 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:DEVOTED HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
157209363
ADMINISTRATOR/
DIRECTOR:		JACKSON, LETICIAFACILITY TYPE:
740
ADDRESS:10311 RIO DEL MAR DRIVETELEPHONE:
(661) 735-7308
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
10/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee/Administrator Leticia JacksonTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/24/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and met with staff Rizaline Osuna. Licensee/Administrator Leticia Jackson was called and arrived shortly. All five residents were present during inspection. Residents were observed in the common area and in the bedrooms. LPA toured facility with Licensee.

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. All residents’ bedroom were toured and observed to have the required furnishings and with adequate lightning. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 40 degrees F and freezer at -4 degrees F. Fire extinguisher was observed with a service date: 01/08/25. Last fire drill was completed on 10/01/25.At 10:24AM, medications were observed unlock on the kitchen counter next to the stove. Medications were check and MARs were reviewed. LPA toured kitchen and observed cleaning chemical stored and locked under kitchen counter. The bathrooms were toured. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 106.4 degree F in the bathroom 1 and maintained at 107.2 and 108.9 degree F in master bathroom. Extra linens and towels were observed. Outside of facility toured and observed to be free of debris. Side exit observed self-closing and self-latching. Adequate outdoor seatings available for residents. Sample of residents’ and staff files were reviewed. Carbon monoxide and smoke detector operational during visit.

A civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached 421IM. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 10/30/25: Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to 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: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2025
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 10/24/2025 01:48 PM - It Cannot Be Edited


Created By: Mai Yang On 10/24/2025 at 01:18 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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, observation, and records review, R2’s morning medications were not administered on 10/24/25 and R1’s medication Cinacalcet 30mg and Benazepril 40 mg as directed by physician, which poses an immediate health and safety risks to persons in care.
POC Due Date: 10/25/2025
Plan of Correction
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Licensee will review regulations and submit written statement detailing steps on how facility will meet regulations by POC due date 10/25/25.

All staff will have in-service re-training on administering medications and medication documentation. Licensee will submit documentation of training which will include trainer’s information and staff attendance roster to the Fresno CCL office by POC due date 10/30/25.
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 R4’s medication pill planner filled with medication tablet unlock on the kitchen counter next to the stove, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 10/25/2025
Plan of Correction
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Staff immediately locked medications. 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: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2025 01:48 PM - It Cannot Be Edited


Created By: Mai Yang On 10/24/2025 at 01:20 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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, licensee did not comply with the section cited above when R3’s medication Citalopram HBR 20 mg was administered daily and not recorded in R3’s Centrally Stored Medication List (Lic 622), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2025
Plan of Correction
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Licensee recorded all R3’s medication into Lic 622 during visit. POC cleared during visit.
Type B
Section Cited
CCR
87465(c)(3)
87465 (c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records reviewed, R1’s medication Multi-50 plus for Her vitamin was not record in the resident’s MAR. 4 out of 5 residents medications were administered on 10/24/25 in the morning and not recorded, which poses a potential health and safety risk for the person in care.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee record all R1’s medications into the R1’s MARs during visit. Licensee will review regulations and submit written statement detailing steps on how facility will meet regulations by POC due date 10/28/25.
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: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


LIC809 (FAS) - (06/04)
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