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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207171
Report Date: 03/11/2026
Date Signed: 03/11/2026 12:51:48 PM

Document Has Been Signed on 03/11/2026 12:51 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:ARC FRESNO/MADERA COUNTIES, REEDLEY TRAINING CTRFACILITY NUMBER:
107207171
ADMINISTRATOR/
DIRECTOR:		WHEELER, KELLYFACILITY TYPE:
775
ADDRESS:1613 12TH STREETTELEPHONE:
(559) 638-5959
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 45CENSUS: 21DATE:
03/11/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Program Director, Kelly WheelerTIME VISIT/
INSPECTION COMPLETED:
12:58 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 3/11/26 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Program Director, Kelly Wheeler, explained reason for visit and was permitted entry into the facility. LPA completed a tour and health and safety check on clients in care. Clients observed programming in activity rooms.

This case management visit is being conducted due to Incident Reports that were received by the department. During visit LPA completed interviews, gathered and reviewed documentation (staff schedule, staff roster, client roster, physicians reports, individual program plans, needs and services plans, case notes and reviewed video footage).

Incident 1 occurred on 2/25/26. R1 was having lunch in activity room when they began choking on their food. Staff preformed the Heimlich maneuver on R1, helping the food to become dislodged. Review of physicians report stated R1 was able to feed themselves. IPP stated mother of R1 prepares meals for R1 to have at program. There is no indication staff need to watch R1 closely while eating. Interviews with staff disclosed that R1 likes to talk during meals and has to be reminded frequently about this distraction while eating. Review of video surveillance and staff schedules show the facility had 2 staff for the 9 clients being supervised during lunch.

Incident 2 occurred on 3/9/26. R2 was having lunch in activity room when they began choking on their food. Staff preformed the Heimlich maneuver on R2, helping the food to become dislodged. Review of physicians report stated R2 is able to feed themselves. IPP stated food is prepared at home for R2 to have at program. R2 is on a chopped mechanical diet. Interviews disclosed staff will chop the food prior to R2 eating it, unless it is pasta/noodles. On this date, food was pre-chopped when check by staff. Review of video surveillance and staff schedule show the facility had 2 staff for the 7 clients being supervised during lunch.

Deficiency cited per California Code of Regulations, Title 22 on 809D. for staffing ratio.

Exit interview completed with Program Director, Kelly. A plan of correction was developed by Program Director and reviewed by LPA. If not corrected the deficiency will have a direct impact to clients in care. A copy of this report, deficiency and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
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 3
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 3
Document Has Been Signed on 03/11/2026 12:51 PM - It Cannot Be Edited


Created By: Mary Garza On 03/11/2026 at 12:33 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: ARC FRESNO/MADERA COUNTIES, REEDLEY TRAINING CTR
FACILITY NUMBER: 107207171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2026
Section Cited
CCR
82065.5(a)(1)

1
2
3
4
5
6
7
82065.5 Staff-Client Ratio (a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
1
2
3
4
5
6
7
Program Director stated clients will be reassessed for assistance with meals and swallowing. Program Director stated they will utilize staffing from other programs if needed on days they are short staffed. Training will be completed with all staff on monitoring residents during eating. Stated they will provide an ongoing plan in writing as proof of correction by POC date.
8
9
10
11
12
13
14
This requirement was not met as evidence by: Records reviewed and LPA observations of video surveillance. The licensee did not comply with the section cited above in that on 2/25/26 staff to client ratio was 2:9 and on 3/9/26 staff to client ratio was 2:7 during supervison of lunch. This poses a potential health safety and or personal rights risk to 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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3