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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203256
Report Date: 11/14/2025
Date Signed: 11/14/2025 03:26:14 PM

Document Has Been Signed on 11/14/2025 03:26 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:CARDIFFFACILITY NUMBER:
157203256
ADMINISTRATOR/
DIRECTOR:		SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:5804 CARDIFF AVENUETELEPHONE:
(667) 837-8177
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
11/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gonzalo CruzTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 11/14/2025, Licensing Program Analyst (LPA) J. Duarte arrived unannounced at the above facility to conduct Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Joseph Dominguez and Administrator, Gonzalo Cruz arrived shortly after. Four residents were observed in the facility. LPA toured the facility with the Administrator.

The facility was observed to be at a 73 degrees F. No fire hazards were observed. LPA observed a seven day supply of non-perishable foods and a two day supply of perishable foods. Fire extinguishers were last serviced on 9/4/2025. Common areas were properly furnished and well-lit throughout. Medications, First Aid, and Resident/Staff files are kept locked in the staff office. Smoke alarm detectors and Carbon monoxide detectors installed and operational.

LPA toured four bedrooms resident rooms. All clients’ bedroom toured and observed to be adequately furnished and lit. Restrooms observed to be clean, odor free and functioning at time of visit. Extra linen and hygiene supply in the hallway closet next to bedrooms. Chemicals are locked in the garage cabinet. Facility has a washer and dryer in the garage and detergent is kept in locked cabinet. LPA observed freezers and a second refrigerator with an additional supply of food. The exterior tour was conducted. Backyard observed to have sufficient seating under patio. A sample of medication were reviewed along with the MAR and records reflect medication to be administered as prescribed. Staff records were reviewed for good health and training. All clients’ records were reviewed to have updated emergency contact information. Per staff records, the last fire drill was conducted on 10/24/2025.

Continued on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 11/14/2025 03:26 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 11/14/2025 at 02:06 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: CARDIFF
FACILITY NUMBER: 157203256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that LPA and Administrator observed knives and other sharps stored in a lock box in a kitchen cabinet; however, the cabinet and the lock box were not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2025
Plan of Correction
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 POC corrected during visit. The administrator placed the lock box with knives and other sharps in a locked cabinet in the garage.
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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/14/2025 03:26 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 11/14/2025 at 02:06 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: CARDIFF
FACILITY NUMBER: 157203256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 that the facility was observed to have broken tiles on the kitchen counter tops, broken kitchen cabinet door, the cabinet under the kitchen sink has water damage and is stained, the kitchen was painted; however, the walls near the refrigerator have not been painted, the hallway light does not work, the sheetrock behind the thermostat is broken, the rug in the dining room is stained and ripped, the side gate latch to the gate near the garage is broken, the facility made stucco repairs to the front of the house; however, the stucco has not been painted, R1's wall near the bed is stained, and the door trim to the doors that lead from the livingroom to the patio is broken. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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The administrator stated that repairs will made and proof of correction will be provided to CCL by POC due date of 12/15/25.
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that LPA and Administrator observed expired milk, yogurt, and cottage cheese in the refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2025
Plan of Correction
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POC corrected during visit. Administrator disposed of expired food during this visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CARDIFF
FACILITY NUMBER: 157203256
VISIT DATE: 11/14/2025
NARRATIVE
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Continued from LIC809.

The following deficiencies were observed: LPA and Administrator observed knives and other sharps stored in a lock box in a kitchen cabinet; however, the cabinet and the lock box were not locked and inaccessible to residents.

The facility was observed to have broken tiles on the kitchen counter tops, broken kitchen cabinet door, the cabinet under the kitchen sink has water damage and is stained, the kitchen was painted; however, the walls near the refrigerator have not been painted, the hallway light does not work, the sheet rock behind the thermostat is broken, the rug in the dining room is stained and ripped, the side gate latch to the gate near the garage is broken, the facility made stucco repairs to the front of the house; however, the stucco has not been painted, R1's wall near the bed is stained, and the door trim to the doors that lead from the living room to the patio is broken.



LPA and Administrator observed expired milk, yogurt, and cottage cheese in the refrigerator.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22. See the attached LIC809D.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 11/28/2025 and provide proof of corrections by Plan of Correction due date.

An exit interview was conducted with Administrator. Report signed on-site and a printed copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
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