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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202449
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:38:33 AM

Document Has Been Signed on 02/06/2025 11:38 AM - 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:PTS FOURFACILITY NUMBER:
157202449
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, MARIANAFACILITY TYPE:
735
ADDRESS:9207 BLOSSOM TIME AVENUETELEPHONE:
(661) 496-8188
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mariana Rodriguez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 02/06/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and was greet by Administrator Mariana Rodriguez. No client was present upon LPA arrival.

LPA toured facility. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 40 degrees F. Fire extinguisher was observed with a service date of: 01/09/24. Fire drill last completed on 02/01/25.



Clients' bedrooms were toured. Bedrooms observed to be adequately furnished and adequate lighting. All bathrooms are toured and observed to be operating. Hot water temperature was tested 110.1 degrees F. in bathroom and range between 119.3 degree F and 119.4 degree F. in master bathroom. Extra linens and hygiene products observed.

Medications were checked and observed kept locked in hall closet. Clients’ MARS was reviewed. Medications were checked. Outside of facility toured. Side gate was self-closing with no debris. Outside was observed with adequate outdoor seatings available for clients. All clients’ and sample of staff files reviewed to have all the required documents. Carbon monoxide and smoke detectors were tested and observed to be operational.

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

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 02/12/25: Lic 308, Lic 500, Lic 610D, and Lic 9020. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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Document Has Been Signed on 02/06/2025 11:38 AM - It Cannot Be Edited


Created By: Mai Yang On 02/06/2025 at 11:15 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: PTS FOUR
FACILITY NUMBER: 157202449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80064(a)(3)
80064 (a)(3) Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has serviced date of 01/09/2024, which poses an immediate health and safety risk to the clients.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 02/07/25.
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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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