107209007-1-21-2025-24-AS-MGAA-DD662P-20250121192551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209007
Report Date: 01/21/2025
Date Signed: 01/21/2025 07:26:05 PM

Document Has Been Signed on 01/21/2025 07:26 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		FACILITY NUMBER:	107209007
ADMINISTRATOR/ DIRECTOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	5727 N. HAZEL AVE		TELEPHONE:	(818) 261-4887
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:01 AM
MET WITH:	Licensee, Jasmin Oganyan		TIME VISIT/ INSPECTION COMPLETED:	07:32 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 01/21/24 Licensing Program Analysts (LPAs) M. Garza and M. Medina arrived unannounced for an annual inspection visit. LPAs were met by Direct Care Staff, John Agustin and Cheryl Nolasco. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPAs completed a health and safety check on residents in care. LPAs toured the facility inside and out. Residents observed in common areas and in rooms. There was 1 resident on hospice and 2 bedridden at the time of the inspection. 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 1/7/2025. Last fire drill completed on 12/03/24. Water temperature measured 116.3 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked closets/rooms. LPAs observed sufficient seating under covered patio areas. The following issues were observed during todays visit: Front entrance observed with stairs and ramp without hand railing. Front door observed with pin and hole at bottom of door. Let us know sign is not properly sized. Living room couch observed with tears and in need of replacement. R1 observed non-ambulatory with wheelchair across living room. Non-perishable food source observed not to be sufficient for 6 residents in care. Over-the-counter medication observed in refrigerator and in kitchen cabinet unlocked and accessible. Hallway vent air circulation observed dirty and in need of replacement. Back door steps observed without hand railing. Patio fan drooping and in need of replacement. Tools observed in backyard unlocked and accessible. Exit gate on side of facility observed locked/stuck closed in need of repair. Backyard fence observed leaning and with broken boards in need of repair. Dog feces observed on walkway and in yard in need of cleaning. LPAs 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-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Exit interview completed with Licensee, Jasmin. A copy of this report, deficiencies and TV's provided.

See Moua	TELEPHONE: (559) -580-4596
Mary Garza	TELEPHONE: 559-365-9009
	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2025

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 01/21/2025 07:26 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	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA interviews with staff and Licensee disclosing 2 residents are bedriddent and LPA observations. The licensee did not comply with the section cited above in 2 of 6 residents are bedridden. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit the LIC 200 and LIC 9054 to CCL to get additional bedridden approval from fire department. Forms will be submitted to CCL by POC date as proof of correction.

Deficiency Dismissed

Type A

Section Cited

HSC

1569.69(e)(3)

Other Provisions

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review of staff records. The licensee did not comply with the section cited above in that 3 of 4 staff files reviewed did not have the required documentation. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Licensee stated a plan of correction in writting will be submitted to CCL by POC date. Plan to include updating personnel files, type of training, time completed, person providing the training, title, signatures and dates. Licensee stated once completed updates will be provided to CCL.

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: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/21/2025 07:26 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	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(c)

Storage Space and Access

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to 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 over-the-counter medication observed in refrigerator and in kitchen cabinet unlocked and accessible. Tools observed in backyard unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee stated tools will be removed and placed in the locked pool area. Medications will be removed and placed into a locked cabinet/closet. Pictures will be provided as proof of correction.

Type B

Section Cited

CCR

87303(a)

(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 observations. The licensee did not comply with the section cited above in living room couch observed with tears and in need of replacement. Hallway vent/air filter observed dirty and in need of cleaning/replacement. Patio fan drooping and in need of replacement. Backyard fence observed leaning and with broken boards in need of repair. Dog feces observed on walkway and in yard in need of cleaning. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee stated corrections will be completed and pictures will be submitted to CCL as proof of correction 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: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/21/2025 07:26 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	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87307(d)

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations. The licensee did not comply with the section cited above in of front entrance observed with stairs and ramp without hand railing. Back door steps observed without hand railing. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee stated hand railing will be installed. Pictures will be supplied to CCL by POC date as proof of correction.

Type B

Section Cited

CCR

87555(a)

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of non-perishable food source. The licensee did not comply with the section cited above in non-perishable food source observed was not sufficient for 6 residents in care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee stated they will purchase additional groceries and supply the recipt as proof of correction.

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: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/21/2025 07:26 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	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87468.1(a)(6)

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. 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 the facility was observed with a locking pin and a hole at the bottom of the front door. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee stated they will throw away the pin. Hole at the bottom of the door will be filled. Picture will be provided to CCL by POC date as proof of correction.

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: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

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