<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209529
Report Date: 10/06/2025
Date Signed: 10/08/2025 09:41:24 AM

Document Has Been Signed on 10/08/2025 09:41 AM - 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 LLC #2FACILITY NUMBER:
157209529
ADMINISTRATOR/
DIRECTOR:		JACKSON, LETICIAFACILITY TYPE:
740
ADDRESS:9319 MANIHIKI AVETELEPHONE:
(661) 491-3032
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
10/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator/ Licensee Leticia Jackson TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/06/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct case management visit and met with Administrator/ Licensee Leticia Jackson.

During the course of the investigation for complaint on 09/09/25, interviews were conducted, records were reviewed, and facility was toured. During tour of the facility, the garage refrigerator was observed not cleaned with food grime. On 09/09/25 visit, LPA was informed R1 was at the hospital. R1 and R2 are receiving hospice care. R2 was observed with full rail bed.

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 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: 10/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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)
Page: 2 of 7
Document Has Been Signed on 10/06/2025 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 10/06/2025 at 10:48 AM
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 #2
FACILITY NUMBER: 157209529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2025
Section Cited
HSC
1569.625(b)(2)

1
2
3
4
5
6
7
HSC 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility shall ensure all staff are trained and training documents are on file. Licensee stated all staff training will be completed by 10/27/25. Staff trainings record shall be submitted to the Fresno CCL by POC due date 10/27/25.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above when all personnel training was not observed on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
10/20/2025
Section Cited
CCR87411(f)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Licensee will submit proof of S1, S2, and S3's health screening to Fresno CCL office by POC due date 10/20/25.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above when LPA reviewed staff files and no health screening were observed on file for 3 out of 4 staff, which poses a potential health or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/06/2025 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 10/06/2025 at 10:54 AM
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 #2
FACILITY NUMBER: 157209529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87211(a) (1)

1
2
3
4
5
6
7
87211(a) (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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:

1
2
3
4
5
6
7
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 10/10/25.
8
9
10
11
12
13
14
Based on record review and interviews: the licensee did not ensure a written was submitted to the Fresno CCL office within 7 days of occurrence on 09/09/25 when R5 went to the hospital, this poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
10/07/2025
Section Cited
CCR87555(b)(21)

1
2
3
4
5
6
7
87555 (b)(21) Freezers of adequate size ...They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff cleaned the garage refrigerator during visit. POC cleared during visit.
8
9
10
11
12
13
14
Based on observation, the refrigerator in the garage was observed dirty food grime inside on the bottom.
8
9
10
11
12
13
14
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: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/06/2025 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 10/06/2025 at 11:01 AM
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 #2
FACILITY NUMBER: 157209529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87633(b)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Licensee will obtain R1’s hospice care plan and submit it to Fresno CCL by POC due date 10/10/25.
8
9
10
11
12
13
14
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 current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
10/10/2025
Section Cited
CCR87608(a)(3)

1
2
3
4
5
6
7
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:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee removed half rails during visit. POC cleared during visit.
8
9
10
11
12
13
14
Based on observation and records reviewed, R3 who do not received hospice care were observed with half with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
8
9
10
11
12
13
14
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: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/06/2025 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 10/06/2025 at 11:06 AM
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 #2
FACILITY NUMBER: 157209529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will complete and obtain appraisal and needs and services plan for R2 and R3 by POC due date. Copies will be submitted to Fresno CCL by POC due date 10/13/25.
8
9
10
11
12
13
14
Based on records review, two out of 6 residents do not have appraisals and needs and services plan on file, which poses/posed a potential health and safety and personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
10/10/2025
Section Cited
CCR87608(a)(5)(B)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Licensee will obtain order for full rail bed for R2 and submitted to the Fresno CCL by POC due date 10/10/25.
8
9
10
11
12
13
14
Based on observation and records reviewed, R2 who receives hospice care were observed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
8
9
10
11
12
13
14
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: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/06/2025 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 10/06/2025 at 11:37 AM
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 #2
FACILITY NUMBER: 157209529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2025
Section Cited
HSC
1569.618(c)(3)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Licensee shall ensure that all staff have current First Aid/ CPR certification. Proof of all staff First Aid/ CPR certification is to be submitted to the Fresno CCL by 10/07/25.
8
9
10
11
12
13
14
All staff files were reviewed, and interviews conducted, staffs not have current First Aid and CPR certification, this poses an immediately health and safety risk for the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7