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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209373
Report Date: 09/16/2025
Date Signed: 09/16/2025 01:49:18 PM

Document Has Been Signed on 09/16/2025 01:49 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:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR/
DIRECTOR:		LEE, WENDYFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(760) 376-1367
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY: 22CENSUS: 22DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Wendy Lee TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 09/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA was greeted by Administrator Wendy Lee and granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with A1. All 22 residents were present during inspection.

The facility was observed to be at a comfortable temperature. The facility was observed clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside.

Kitchen was toured. An adequate supply of perishable and non-perishable food was observed. Dishwasher was observed operational during inspection.

Medications observed kept locked in medication cart in the facility office. MARs were reviewed and medications were checked. Cleaning solutions observed stored and locked under kitchen sink and under staff bathroom sink. Refrigerator temperature was maintained at 38 degrees F and freezer temperature was maintained at 0 degrees F. Sharps observed locked in kitchen drawer. Fire extinguishers were observed throughout the facility with a service date of 05/05/25.

All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature.

Bathrooms were properly equipped. Bathrooms hot water temperature was tested at 112.8 degrees F in room 11, 110.4 degrees F in room 10, and 112.6 degrees F in room 8. LPA observed chemicals stored and locked in the laundry room and shed 1.

CONTINUED TO Lic 809C

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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 09/16/2025 01:49 PM - It Cannot Be Edited


Created By: Mai Yang On 09/16/2025 at 12:55 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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
HSC
1569.185(e)
HSC 1569.185(e) Fees for license or applications; use of revenues; collected; denial or forfeiture. The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.

This requirement was not met by:
Deficient Practice Statement
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The facility annual fee is overdue with a past due amount of $1,485.00, this poses potential health and safety risk to residents in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee to bring account current prior to due date 10/10/25. Facility Transaction History report CLF551M0 provided.

Licensee shall provide proof of annual fees have been renewed and current to Fresno CCL by due date 10/10/25.
Deficiency Dismissed
Type B
Section Cited
CCR
87411(f)
87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 and A1 confirmed S1 and S2’s files and observed no health screening were on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator obtain S1's physical health screening during visit. Administrator will submit proof of S2’s health screening to Fresno CCL by POC due date 09/26/25.

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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 01:49 PM - It Cannot Be Edited


Created By: Mai Yang On 09/16/2025 at 12:57 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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
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 review 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: 09/19/2025
Plan of Correction
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Administrator will obtain R1’s hospice care plan and submit it to Fresno CCL by POC due date 09/19/25.
Type B
Section Cited
CCR
87609(b)(4)
87609 (b)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview conducted, the licensee did not comply with the section cited above when LPA review R2’s file, whose currently receiving home health with no home health records and care plan on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Administrator will obtain R2’s home health record and submit it to Fresno CCL by POC due date 09/19/25.
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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373
VISIT DATE: 09/16/2025
NARRATIVE
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Outside of the facility toured and observed to be free of debris. Adequate outdoor seating was observed to be available for residents. Designated smoking area observed available for residents. LPA observed fence gates on each side of the courtyard locked. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of resident and staff files were reviewed to have all the required documents.

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

Exit Interview conducted. A copy of current Administrator Certificate was received. The following documents are requested and submitted to Fresno CCL by: 09/22/25. Forms requested: Lic 308, Lic 500, current liability insurance, Lic 610E, and current Administrator certificate. A copy of this report 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: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/16/2025 01:49 PM - It Cannot Be Edited


Created By: Mai Yang On 09/16/2025 at 01:15 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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
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, interview conducted and observation, S2 is working providing care for residents. S2 is fingerprinted cleared who is not associated to facility, which poses an immediate risk to the health and safety of the residents.
POC Due Date: 09/17/2025
Plan of Correction
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S2 is to be removed from the facility immediately. S2 is not permitted back until associated. Licensee is to submit LIC 9182 or associate S2 on Guardian. Proof of S2 associated to the facility will be submitted to Fresno CCL by POC due date 09/17/25.
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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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