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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 08/08/2025
Date Signed: 08/08/2025 01:42:39 PM

Document Has Been Signed on 08/08/2025 01:42 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:NAN'S TLC HOMEFACILITY NUMBER:
107201038
ADMINISTRATOR/
DIRECTOR:		NEWELL-PARANGALAN, LUZFACILITY TYPE:
740
ADDRESS:6643 N. MAROA AVENUETELEPHONE:
(559) 439-2465
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 3DATE:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Luz Newell-Parangalan, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 08/08/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a required Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Licensee/Administrator Luz Newell-Parangalan. Two residents were present during inspection.

LPA toured facility with Licensee. Residents were observed in the common area. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Last fire drill was completed on 03/02/25. Fire extinguisher was observed with a serviced date of 02/21/25. Medications were observed kept locked in hall closet. Residents’ MARS was reviewed, and medications were checked. An adequate supply of perishable and non-perishable food was observed. Cleaning chemicals were observed locked in the garage. Extra linens observed.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were toured and observed functional. Non-skid mats and grabbed bars were observed.

Hot water temperature was tested range at 106.9 and 197.6 degree F in master bathroom and 106.3 and 105.4 degree F in bathroom. Outside of facility toured. Side gate was self-closing and self-latching. Adequate outdoor seatings available for residents. Carbon monoxide and smoke detectors was operational during inspection. All residents’ and sample of staff files were reviewed.

Technical Support Program (TSP) assistance was offered. Licensee and will make a decision and reach out the department regarding acceptance.



A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 08/14/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of these report.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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 08/08/2025 01:42 PM - It Cannot Be Edited


Created By: Mai Yang On 08/08/2025 at 12:50 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

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 observation and records reviewed, Medication was checked. LPA and Licensee observed R1 and R2’s medications were not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 08/09/2025
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 08/09/25.

Type A
Section Cited
CCR
87309(a)
87309 (a) Except as specified in subsection (b), 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 was not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA and L1 observed a knife unlock in kitchen drawer unlock accessible to the residents, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 08/09/2025
Plan of Correction
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Licensee immediately removed the knife into locked kitchen shelf. 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: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/08/2025 01:42 PM - It Cannot Be Edited


Created By: Mai Yang On 08/08/2025 at 12:51 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

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…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R1’s medication Folic Acid 1 mg and Clotrimazole. R2’s medication Folic Acid 1 mg, Glipizide 10mg, and Levothyroxine 0.025mg, and R3’s medication Azelastine 0.1% were not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the
resident in care.
POC Due Date: 08/14/2025
Plan of Correction
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Lic 622 all residents’ current medication recorded shall be completed and submitted to the Fresno CCL by POC due date 08/14/25.
Type B
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 records reviewed and interview conducted with Licensee, all residents medications were administered daily. MAR is not recorded when medications administered, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 08/14/2025
Plan of Correction
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All staff retrained in in-service medication training in proper medication administering, documentations, and verification. Proof training completed and staff rooster of attendance will be submitted to Fresno CCL by POC due date 08/14/25.
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: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 01:42 PM - It Cannot Be Edited


Created By: Mai Yang On 08/08/2025 at 12:52 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interview conducted, observation, records reviewed, R2 is not receiving hospice care, was observed lying bed using a hospital bed with full rail with doctor’s order, which poses/posed a potential health and safety and personal risk to the resident in care.
POC Due Date: 08/14/2025
Plan of Correction
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Full bed rails are prohibited. If half bed rail is needed for R2, Licensee shall obtain doctor orders for half bed rail and indicating the need for half bed rail. Full bed rail must be removed by POC 08/14/25.
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, records reviewed, R1 has an electric hospital bed with no doctor’s order and R3 has a half rail bed with no doctor’s order, which poses/posed a potential health and safety and personal risk to the resident in care.
POC Due Date: 08/14/2025
Plan of Correction
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Licensee stated will obtain doctor’s order for R1’s hospital bed by POC due date. Half rail shall be removed by POC due date, if doctor indicates R3 needs half bed rail. A doctor’s order for R3’s half bed rail shall be obtained and indicate the need for half bed rail. If orders are obtained by the physician, the order will be submitted to Fresno CCL by POC due date 08/14/25.
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: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/08/2025 01:42 PM - It Cannot Be Edited


Created By: Mai Yang On 08/08/2025 at 12:53 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(1)(17)
87506 (b)(1)(17) Each resident’s record shall contain at least the following information: (1) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; (B) Section 87459, Functional Capabilities; (C) Section 87461, Mental Condition; (D) Section 87462, Social Factors; (E) Section 87463, Reappraisals; and (F) Section 87505, Documentation and Support

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, all the residents was not observed with a needs and services plan on file, which poses/posed a potential health and safety and personal risk to the resident in care.
POC Due Date: 08/14/2025
Plan of Correction
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Needs and Services plan shall be completed for all the residents and submitted to the Fresno CCL by POC due date 08/14/25.
Section Cited
Deficient Practice Statement
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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: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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