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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209492
Report Date: 06/17/2025
Date Signed: 06/17/2025 02:02:25 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
05/13/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250513154609
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:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Karen Dhaliwal and Licensed Vocational Nurse Diane CramerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff do not ensure residents expired medications are discarded
INVESTIGATION FINDINGS:
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On 06/17/25, 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 and Licensed Vocational Nurse Diane Cramer. LPA delivered complaint findings.

During the course of the investigation, the Department conducted interviews, toured the facility, and reviewed records. Discontinued medications were stored in medication room unlogged and not disposed. Interview with staff confirms expired medications and medications for former residents has not been logged and disposed back dated to March 2025. Based on observations and interviews conducted, the preponderance evident has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20250513154609
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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2025
Section Cited
CCR
87465(i)
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87465 (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction.

This requirement is not met as evidenced by:
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All medications to be disposed shall be destroyed and recorded. Administrator will submit documentation of steps facility will take to ensure disposed medications are record and destroyed properly and timely to Fresno CCL by POC due date 06/18/25.
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Based on interview conducted and observations, medications for expired residents and discontinued medications were not record nor destructed backdating to March 2025, in which poses/posed a potential health and safety and personal rights risk to the resident 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: 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
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
05/13/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250513154609

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:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Karen Dhaliwal, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff handled resident in a rough manner resulting in resident sustaining a minor injury
Staff do not ensure resident is kept in clean dry clothing at all times
Staff not responding to client's calls for assistance in a timely manner
Staff do not ensure residents clean laundry is returned in a timely manner
Staff dispensed incorrect medications to residents in care

INVESTIGATION FINDINGS:
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On 06/17/25, 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. LPA delivered complaint findings.

During the course of the investigation, the Department conducted interviews, toured the facility, and reviewed records. R1 confirmed no injury was sustained while reside at faciliy. Facility is doing resident’s laundry on laundry schedule date, after resident’s shower date, and as needed. Staff completed required trainings and are redirecting residents. Based on interview conducted, observation, and records reviewed, there was insufficient evidence to prove or disprove that staff did not ensure that residents are provided with a safe environment, staff not properly trained, and staff did not provide adequate laundry services. Therefore, the above allegations are found to be UNSUBSTANTIATED. 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: 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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3