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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209492
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:04:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250311151837
FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR:DHALIWAL, KARENFACILITY TYPE:
740
ADDRESS:14280 W STANISLAUS AVETELEPHONE:
(661) 972-4646
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:54CENSUS: 37DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Karen DhaliwalTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee does not ensure that facility's appliances are maintained in good repair
INVESTIGATION FINDINGS:
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On 03/12/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal.

During the course of the investigation, LPA conducted interviews, toured the facility, and reviewed records. Refrigerators were observed operational and in good repair. Refrigerator temperature was maintained at 36 degrees F. Frozen food was observed stored in refrigerator. A freezer was observed in the facility kitchen non-operational.

Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBTANTIATED. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20250311151837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107209492
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/13/2025
Section Cited
CCR
87555(b)(21)
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87555 (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
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Facility has a new freezer that arrived on 03/11/25 and not being put in use to store frozen food. New freezer will be plug in and utilized by POC due date.
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Based on interviews conducted, observation, and records reviewed, the facility did not have a working freezer for over two weeks to store frozen food, which poses/ posed a potential health and safety risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2025 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20250311151837

FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR:DHALIWAL, KARENFACILITY TYPE:
740
ADDRESS:14280 W STANISLAUS AVETELEPHONE:
(661) 972-4646
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:54CENSUS: DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Karen DhaliwalTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Licensee does not ensure that facility food is free from contamination
INVESTIGATION FINDINGS:
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7
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On 03/12/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal.

During the course of the investigation, LPA conducted interviews, toured the facility, and reviewed records. Adequate food supplies was observed stored in refrigerator with no contamination. Based on observation, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be UNSUBTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3