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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209543
Report Date: 04/17/2025
Date Signed: 04/17/2025 12:22:41 PM

Document Has Been Signed on 04/17/2025 12:22 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:ELIM PLACEFACILITY NUMBER:
107209543
ADMINISTRATOR/
DIRECTOR:		CEBALLOS, MARIAFACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(650) 776-2280
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY: 44CENSUS: 26DATE:
04/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee Elsa Nguyen, Administrator Maria Ceballos, and Administrator Assistant Christina GomezTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 04/17/25, Licensing Program Analyst (LPA) M. Yang conducted a Pre-licensing and Component III inspection for Change of Ownership. Upon arrival LPA delay egress door. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Elsa Nguyen, Administrator Maria Ceballos, and Administrator Assistant Christina Gomez. All 26 residents were present during inspection.

Fire clearance was granted for 44 non-Ambulatory for total of 44 capacity. Delayed egress doors observed.
A sample of resident files were reviewed to have Admission Agreements, Physician Reports, and Pre-Appraisal. A sample of staff files were reviewed to have a criminal record clearance, fingerprinted clearance, and good health screening. Chemicals observed stored and locked in locked housekeeping closet. Facility dryer observed operating during inspection. Fire extinguisher observed throughout the facility with serviced date 03/11/25 and 03/06/25. LPA observed an extra supply of bed linens and personal hygiene products. All resident bedrooms were observed to have required furnishings and lighting.

All bathrooms were toured. Bathrooms are observed with securely fastened grab bars and non-skid mat. Hot waters were tested at 118 degrees F in bathroom 1, 123 degrees F in bathroom 2, 85.3 degrees F in bathroom 3, 88.3 degrees F in bathroom 4, and 71.7 degrees F in bathroom 5. Courtyard was observed free of debris and adequate outdoor seatings observed available for residents.Medications observed locked in medication cart in the medication room. First aid kit was observed and contained all required items. Carbon monoxide and smoke detector tested operational during visit. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Temperatures maintain at 38 degrees F in refrigerator 1 and -11 degrees F in freezer. First Aid kit observed with gauze, bandages, a roller, and trauma pad.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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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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: ELIM PLACE
FACILITY NUMBER: 107209543
VISIT DATE: 04/17/2025
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The following observed will need to be brought into compliance:
1. Fire clearance for delay egress
2. All bathroom’s temperature to be range between 105 and 120 degrees F.
3. First Aid kit with required items: First aid manual approved by the American Red Cross, the American Medical Association, Sterile first aid dressings, sterile first aid dressing, bandages, scissors, tweezers and thermometers.

A follow up inspection will be scheduled once all above items are in compliance. Exit interview conducted. A copy of this report was provided to Licensee.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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