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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209542
Report Date: 07/07/2026
Date Signed: 07/07/2026 12:54:29 PM

Document Has Been Signed on 07/07/2026 12:54 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ANNAI HOUSEFACILITY NUMBER:
107209542
ADMINISTRATOR/
DIRECTOR:		KENDAKUR, SUNDARI SUSANFACILITY TYPE:
740
ADDRESS:175 W SIERA AVETELEPHONE:
(559) 779-4071
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 49CENSUS: 35DATE:
07/07/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Julijean De CastroTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Staff schedule shows that there are an average of 9 staff on the schedule on a daily basis. Some individual residents require complete assistance with all of the daily living. This was not cited on this inspection, but is cited on the Case Management for 7/7/26.

LPAs reviewed medications and medication binders for residents and found that there were no errors.

LPA reviewed the pest control service being provided.
Facility was made aware that all restrooms must provide paper towels.
Plan of Operation was not available for review at the facility.
Facility has a portion of the staff and resident files on a computerized system and limited documents can be seen on a tablet.
Laundry services include two sets of washer/dryers. All resident rooms were observed to have clean linens.
First Aid kit was observed and found to be adequate.

LPAs requested Licensee to submit the following documents by 07/28/2026: LIC308, LIC500, updated LIC9020, Proof of Liability Insurance, Surety Bond, LIC610E, Infection Control Plan.
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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 07/07/2026 12:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/07/2026 at 11:39 AM
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: ANNAI HOUSE
FACILITY NUMBER: 107209542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87706(a)(1)
Advertising Dementia Special Care, Programming, and Environments
(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that LPA did not observe a Dementia care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Facility to provide the current Plan of Operation which shall include the Dementia Care Plan.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 resident rooms, no screens were observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Facility to provide screens on all windows of the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2026 12:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/07/2026 at 11:39 AM
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: ANNAI HOUSE
FACILITY NUMBER: 107209542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(7)
General Food Service Requirements
(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident 1 file, no prescription for diabetic diet was observed. Kitchen staff did not have a copy of the diabetic diet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Facility shall obtain a diet written and/or prescribed by a doctor, for any diabetic client living at the facility.
Type B
Section Cited
CCR
87506(b)(11)
Resident Records
(b) Each resident's record shall contain at least the following information: (11) The documentation required by Section 87611(a) for residents with an allowable health condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in resident 5 has a colostomy bag and has no doctors care plan for this allowable, restricted condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Facility must obtain proper documentation from the residents doctor required by Section 87611(a) for residents with an allowable health condition.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2026 12:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/07/2026 at 11:55 AM
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: ANNAI HOUSE
FACILITY NUMBER: 107209542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
87208(a) The licensee shall have and maintain a current, written definitive plan of operation for the faciltiy. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that no Plan of Operation was found at the facility. The Plan of Operation found at the Licensing Office was reviewed and it was found that it did not include mental health, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Facility to submit a plan to Licensing which includes mental health or the facility shall remove the clients that fall under this description.
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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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