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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209492
Report Date: 06/17/2025
Date Signed: 06/17/2025 02:01:48 PM

Document Has Been Signed on 06/17/2025 02:01 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:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR/
DIRECTOR:		DHALIWAL, KARENFACILITY TYPE:
740
ADDRESS:14280 W STANISLAUS AVETELEPHONE:
(661) 972-4646
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY: 54CENSUS: 37DATE:
06/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane CramerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 06/17/25, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the
Required Annual Inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane Cramer. LPA toured facility with Administrator.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Last fire drill completed on 3/25/25. Fire extinguisher was observed throughout facility with a service date of: 06/13/25. Medications were stored in medication carts. MARs, Centrally Stored Medication List were reviewed, and medications were checked. LPA toured a sample of residents’ room were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathroom was toured and observed with securely fastened grab bars and non-skid mat. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored. Temperature was maintained at 31 degree F. in refrigerator and freezer temperature was maintained at -7.4 degree F. Chemicals was stored and locked in housekeeping closet. Washer and dryer observed operational and functioning. Extra linens observed. The outside was toured and observed to be free from debris. There was outdoor seating available for the residents in courtyard. Fire alarm systems observed throughout facility.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A
civil penalty is being assessed see attached Lic 421IM.

An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 06/23/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator certificate, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirm receipt of these reports.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
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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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)
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Document Has Been Signed on 06/17/2025 02:01 PM - It Cannot Be Edited


Created By: Mai Yang On 06/17/2025 at 12:40 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: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107209492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2025

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
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Based on records review and observation, R4’s medication Metformin Hcl 500 mg and R3's medication Losartan was not administered as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 06/18/2025
Plan of Correction
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All medication technicians will be re-trained on medications trainings. Documentation of training topics and materials with staff attendance rooster will be submitted to Fresno CCL by POC due date 06/18/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/17/2025 02:01 PM - It Cannot Be Edited


Created By: Mai Yang On 06/17/2025 at 12:40 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: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107209492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted, observation, and records reviewed, R3’s medication Atorvastatin 40 mg and Donepezil Hcl 5 mg were administered daily and not record in Centrally Stored Medication List (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 06/20/2025
Plan of Correction
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R3’s medications shall be recorded in Lic 622 and submitted to the Fresno CCL by POC due date 06/20/25.
Type B
Section Cited
CCR
87608(a)(5)(B)
87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R1 and R2 are on hospice care lying bed using a hospital bed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 06/23/2025
Plan of Correction
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Full bed rails are prohibited. Licensee shall obtain doctor orders for R1 and R2 that specific the need for half bed rails and remove full bed rails by POC due date 06/23/25.
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: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2025


LIC809 (FAS) - (06/04)
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