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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209360
Report Date: 10/02/2025
Date Signed: 10/03/2025 09:47:35 AM

Document Has Been Signed on 10/03/2025 09:47 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:NORTHWEST VILLAFACILITY NUMBER:
107209360
ADMINISTRATOR/
DIRECTOR:		ROYCHOUDHURY, MINAKSHIFACILITY TYPE:
740
ADDRESS:542 W. BROWNING AVENUETELEPHONE:
(559) 448-8964
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 6DATE:
10/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Administrator (A1) Shailesh "Steve" Patel TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 10/02/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct required Annual visit. LPA introduced self, stated the purpose of the visit, and was greeted by staff (S1) Mansi Mansi. Administrator (A1) Shailesh "Steve" Patel arrived shortly during inspection. LPA toured facility with A1. Five residents were present during inspection. One resident left during inspection with family. Licensee Rajat Roychoudhury arrives shortly during inspection and left facility shortly.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. LPA and S1 observed R3 walking in and using staff bathroom. Medications observed kept locked in kitchen shelf and in laundry room shelf. Medications were checked. Centrally stored medications list and MARs were reviewed.

At approximately 09:19AM, LPA and A1 observed cleaning solutions stored under kitchen sink unlock. Fire extinguisher was observed in the kitchen cabinet with last serviced date of 09/11/25. A1 stated last fire drill completed on 02/2025. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37 degrees F and freezer temperature at -17 degrees C. Chemicals observed locked in laundry shelf. At approximately 10:20AM, chemicals were observed stored unlock under laundry counter.

Lic 809 continues

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
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 12
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 12
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: NORTHWEST VILLA
FACILITY NUMBER: 107209360
VISIT DATE: 10/02/2025
NARRATIVE
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All bathrooms were toured. At approximately 10:26AM, LPA and A1 observed multiple medications under the staff bathroom sink. Under the staff bathroom sink was observed in disrepair. All bedrooms were observed to have the required furnishings and adequate lighting. At approximately 10:32AM, a chemical bottle was observed in room 1 bathroom shelf unlocked. Hot water temperature was tested maintained at 109.8 degrees F in bathroom 1, 107.1 degrees F in room 3 bathroom, 96.4 degrees F in room 4 bathroom, and 112.6 degrees F in bathroom 2. Toilet observed functional. Extra linens and towels were observed in hall closet. R1 was observed lying in bed with full rail. Room 4 was observed with half rail bed.

Outside of the facility toured and observed to be free of debris. The side gate observed self-closing and self-latching. Adequate outdoor seating observed for residents. At approximately 10:44AM, LPA and A1 observed multiple paint cans and a gardening tool stored unlock in outside storage. At 12:36PM, LPA and A1 observed a hole on the wall by the front door. All residents and staff files reviewed. Smoke detectors and carbon monoxide observed operational during inspection.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6 see attached 809D.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/08/25. Forms requested: Lic 308, Lic 500, Lic 610E, Lic 9020, current administrator certificate, and current liability insurance. A copy of this report and appeal rights 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: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:22 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed multiple medications stored under staff bathroom unlock, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 10/03/2025
Plan of Correction
1
2
3
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Administrator immediately removed medication into locked medication shelf. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(1)
87465 (c)(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interviews conducted, observation, and records reviewed, R3’s medication Medihoney gel was administered as needed by staff with no doctor’s orders, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 10/03/2025
Plan of Correction
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2
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Administrator removed medication and will destroy medication. 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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:24 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

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
1
2
3
4
Based on observation, records reviewed, and interview conducted, R1’s medication Ferrous Sulfate and R5’s medication Melatonin 10mg were checked by LPA and Administrator and observed not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 10/03/2025
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 10/03/25.

All staff will be retrained on administering medications. Documentation of training topics and materials including date, training instructor, and staff attendance rooster to the Fresno CCL office by 10/15/25.
Type A
Section Cited
CCR
87411(c)(1)
87411(c)(1) Staff providing care shall receive appropriate training in first aid…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview conducted and records reviewed, all staff files were reviewed and did not have current First Aid certification on file, this poses an immediately health and safety risk for the residents in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee shall ensure that staff have current First Aid and CPR certification. Proof First Aid certification for all staff is to be submitted to the Fresno CCL by 10/03/25.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:25 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA observed at cleaning solutions under kitchen sink, chemicals under counter in laundry room, a bottle of Hydrogen Peroxide in room 1 bathroom shelf, and paint cans with gardening tool in the backyard all unlock, accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Administrator immediately locked chemicals and tools. POC cleared during visit.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:26 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review and interview, the licensee did not comply with the section cited above when A1 and S3’s personnel file was not observed maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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2
3
4
Licensee will submit a written statement detailing the steps the facility will take to ensure the requirements for section 87412 are met to and have A1 and S3 files at the facility by POC due date. Statement will be submitted to the Fresno CCL office by POC due date 10/08/25.
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 and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and records reviewed, R1’s as needed medication Tylenol 500mg and medication Ferrous Sulfate and R3’s medication Quetiapine 50 mg and medication Amlodipine Sodium 70mg were not record in Centrally Stored Medication record, poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 10/03/2025
Plan of Correction
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2
3
4
Administrator recorded all R1 and R3’s medication into centrally stored medication list during visit. 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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:28 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 (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 observation, a hole was observed on the wall by the front door and under the staff bathroom sink is in disrepair, poses/posed a potential health and safety and personal rights risk to the resident in care.

POC Due Date: 10/20/2025
Plan of Correction
1
2
3
4
Under staff bathroom sink and hole on the wall shall be in good repair by POC due date. Proof of repair will be submitted to the Fresno CCL by POC due date 10/20/25.
Type B
Section Cited
CCR
87211(a)(1)
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 was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview conducted, Licensee did not submit a written report to the department within 7 days of incident when R5 had went to the hospital on 09/26/25, this poses a potential health and safety risk to residents in care.
POC Due Date: 10/08/2025
Plan of Correction
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2
3
4
Licensee will submit review Reporting Requirements regulation, and a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date 10/08/25.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:29 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)
87412 (c)(2) Documentation of staff training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above when all staff files did not have the proper documentation and required trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
1
2
3
4
Licensee shall ensure that all staff have required trainings and continued trainings recorded. Licensee will submit a written statement detailing the steps the facility will take to ensure all staff training have the proper documentation including trainer’s full name, subject covered in the training, date of the training, number of hours of training per subject. Written statement will be submitted the Fresno CCL office by POC due date 10/06/25.
Type B
Section Cited
CCR
87458(b)(1)
87458(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any
and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions
which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed, R1 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
1
2
3
4
Proof of TB result for R1 will be obtained and submitted to Fresno CCL by POC due date 10/15/25.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 02:34 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
HSC 1569.695(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in the drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews conducted with Administrator, last emergency disaster drill was completed on 02/2025 and not recorded, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 10/15/2025
Plan of Correction
1
2
3
4
Licensee shall ensure emergency disaster drills are completed quarterly and documented. Emergency drill is to be completed and submitted to the Fresno CCL by POC due date 10/15/25.
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
1
2
3
4
Based on interview conducted, observation and records reviewed, R1 uses a half rail bed. There is no doctor’s order for ½ rail bed for R1, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 10/03/2025
Plan of Correction
1
2
3
4
Administrator removed half rail from bed. 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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 03:19 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
87465 (c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and records reviewed, R1’s medication Melatonin 5mg was not record in the resident’s MAR, which poses a potential health and safety risk for the person in care.

POC Due Date: 10/03/2025
Plan of Correction
1
2
3
4
Administrator record all R1’s medications into the resident’s MARs during visit. POC cleared during visit.

Type B
Section Cited
CCR
87411(d)(3)
87411(d)(3) Personnel Requirements – General Skill and knowledge required to provide necessary
resident care and supervision, including the ability to communicate with residents.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed and interviews conducted, R1 is receiving hospice resident requires assistant using Hoyer lift, in which the facility did not provided nor trained on the using the Hoyer lift, This poses a potential health and safety risk to residents in care.
POC Due Date: 10/15/2025
Plan of Correction
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2
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4
Licensee will have staff in-service training on using Hoyer lift. Training documents with staff rooster of attendance shall be submitted to CCL by 10/15/25.
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: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 10/03/2025 09:47 AM - It Cannot Be Edited


Created By: Mai Yang On 10/02/2025 at 03:48 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)
87506 (b)(17) Documents and information required…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, all residents file were reviewed and observed R3 do not have an appraisal (Lic 603) and needs and services plan (Lic 625) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
1
2
3
4
Licensee shall ensure that all residents have the required records on file. R3’s Lic 603 and Lic 625 will completed and submitted the Fresno CCL office by POC due date 10/08/25.
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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 12 of 12