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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209425
Report Date: 03/18/2025
Date Signed: 03/18/2025 01:29:08 PM

Document Has Been Signed on 03/18/2025 01:29 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:AMERICAN SENIOR LIVINGFACILITY NUMBER:
157209425
ADMINISTRATOR/
DIRECTOR:		JUAREZ, LINA F DIAZFACILITY TYPE:
740
ADDRESS:9003 DROVERS RUN RDTELEPHONE:
(661) 493-8209
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 4DATE:
03/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:08 PM
MET WITH:Licensee/Administrator Lina Juarez and staff Shervin MohammadiTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On 03/19/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct a case management-deficiency
visit. LPA met with Licensee/Administrator (L1) Lina Juarez and staff(S1) Shervin Mohammadi.

During the annual inspection on 03/18/25, LPA reviewed residents record and conducted interviews. L1 and S1 stated R1 had went to the hospital on 02/13/25 and 02/25/25 and was not reported to the department Records were reviewed and confirmed resident to the hospital.

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

An exit interview was conducted. A copy of this report and appeal rights was provided to Licensee, whose
signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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Document Has Been Signed on 03/18/2025 01:29 PM - It Cannot Be Edited


Created By: Mai Yang On 03/18/2025 at 01:10 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: AMERICAN SENIOR LIVING
FACILITY NUMBER: 157209425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require… (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...

This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date 03/21/25.
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Based on record review and interviews, the Licensee did not ensure a written incident report was submitted to the department within 7 days of occurrence when R1 went to the hospital on 02/13/25 and 02/25/25, this poses/posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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