107208887-1-23-2025-24-AS-MGAA-DD84LC-20250123181142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208887
Report Date: 01/23/2025
Date Signed: 01/23/2025 06:11:48 PM

Document Has Been Signed on 01/23/2025 06:11 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:	FIVE STAR ASSISTED LIVING CORP		FACILITY NUMBER:	107208887
ADMINISTRATOR/ DIRECTOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	2573 W. BARSTOW AVE		TELEPHONE:	(559) 283-8543
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:23 AM
MET WITH:	Administrator, Jasmine Oganyan		TIME VISIT/ INSPECTION COMPLETED:	06:21 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 5/12/23 Licensing Program Analysts (LPAs) M. Garza and L. Salazar arrived unannounced for an annual inspection visit. LPAs were met by Direct Care Staff, Esther and Henry Alsisto explained reason for visit and was permitted entry into the facility. Administrator, Jasmine Oganyan was contacted and arrived some time later. LPAs completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 4 residents on hospice and 2 bedridden at the time of visit. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 1/7/25. Last fire drill on 11/24/24. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. LPA observed sufficient seating under covered patio areas. The following issues were observed during time of visit: Facility sketch needs meeting point designated. 2 of 6 residents observed with hospital beds with hand railings and not on hospice. Bathroom #2 floor is not slip-resistant. Air vents in Bathroom #2 is rusted/dirty and in need of cleaning/replacement. Bathroom #2 baseboard in need of repair/replacement. Bathroom #2 light switch broken and in need of repair. Fence on right side leaning and in need of repair. Debris observed in pool area in need of removal. Concrete walkway in back of house observed with a lip (possible tripping hazard) in need of repair. Debris observed by storage shed in need of removal. CONT...

See Moua	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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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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: FIVE STAR ASSISTED LIVING CORP	FACILITY NUMBER: 107208887
	VISIT DATE: 01/23/2025

NARRATIVE

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CONT...

Chemicals/sharps/items posing danger to residents observed throughout the facility unlocked and accessible. First Aid kit missing instruction guide. Bedroom #6 observed with a broken window in need of repair. Pool fence in need of repair. Quick release bars observed on windows.

An immediate danger was not observed for pool fence due to the non-ambulatory status of the residents and their inability to leave the facility without assistance. The Department will review original fire clearance for approval of window bars. If deficiency is warranted, they will be issued at a later time. Immediate civil penalty assessed in the amount of $500 for bedridden resident.

LPA requested the following documents to be submitted to CCL by 1/31/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview completed with Administrator, Jasmine. A copy of this report, deficiencies and TV's provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 06:11 PM - It Cannot Be Edited

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: FIVE STAR ASSISTED LIVING CORP	FACILITY NUMBER: 107208887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in facility having 2 bedridden residents. Review of resident LIC 602's indicated bedridden for 2 of 6 residents. Facility is only approved for 1 bedridden resident. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee will submit a plan of correction in writting to CCL by POC date. Plan to include getting R1 an updated LIC 602 and providing video.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/23/2025 06:11 PM - It Cannot Be Edited

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: FIVE STAR ASSISTED LIVING CORP	FACILITY NUMBER: 107208887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in chemicals, sharps and items posing a danger observed unlocked and accessible throughout the facility. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Administrator stated they will purchase new locks for the cabinets. Administrator will provide receipt as proof of correction by POC date to CCL.

Type B

Section Cited

CCR

87307(e)(2)(A)

Personal Accommodations and Services (e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that pool fence observed with open area on left side not completely surrounding pool, in need of repair. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Administator stated they will get gate fixed and provide pictures as proof of correction to CCL by POC date.

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	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/23/2025 06:11 PM - It Cannot Be Edited

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: FIVE STAR ASSISTED LIVING CORP	FACILITY NUMBER: 107208887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in air vents in Bathroom #2 is rusted/dirty and in need of cleaning/replacement. Bathroom #2 baseboard in need of repair/replacement. Bathroom #2 light switch broken and in need of repair. Fence on right side leaning and in need of repair. Debris observed in pool area in need of removal. Concrete walkway in back of house observed with a lip (possible tripping hazard) in need of repair. Bedroom #6 observed with a broken window in need of repair. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Administrator stated corrections will be made. Pictures showing corrections completed will be sent to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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