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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206846
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:20:18 PM

Document Has Been Signed on 02/20/2025 02:20 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:TEHACHAPI MANORFACILITY NUMBER:
157206846
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, LORENAFACILITY TYPE:
740
ADDRESS:20400 OAK KNOLL DR.TELEPHONE:
(661) 822-7885
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:43 PM
MET WITH:Lorena Rodriguez, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 02/20/25, Licensing Program Analysts (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and request to meet with Administrator. LPA met with staff Alejandra Gaitan. Licensee Lorena Rodriguez was called and arrived shortly. Three resident was present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Outside observed free of debris. Fire extinguisher was observed with a service date of: 12/27/24. Temperature maintained for refrigerator at 34 degrees F and freezer maintained at 0 degrees F. An adequate supply of perishable and non-perishable food was observed. Medications observed kept locked in laundry room. MARs were reviewed. Cleaning supplies and chemicals stored and locked in laundry room.

All bedrooms were observed to have required furnishings and with adequate lighting. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 105 hall bathroom, room 3 and room 4 tested at 110.5 and 110.8 degrees in shared bathroom, and room 4 and room 5 110.3 and 110.4 degrees F in shared bathroom. Outdoor seatings observed available for residents. Smoke detectors were tested and observed to be operational. All residents’ and a sample of staff files were reviewed to have all required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 02/26/25. Forms requested: Lic 308, Lic 500, Lic 610E, Lic 9020, current liability insurance, control of property, and current Administrator Certificate. A copy of this report and appeal rights was provided to the Licensee, whose signature on this form confirms receipt of this report.
See MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 02/20/2025 02:20 PM - It Cannot Be Edited

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: TEHACHAPI MANOR
FACILITY NUMBER: 157206846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, staff did not administer R1’s medication Escitalopram 10mg as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee shall submit written plan of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 02/21/25.

Licensee shall have all staff retrained on administering medications. Licensee will submit documentation of training topics with staff attendance rooster to the Fresno CCL office by 02/26/25.
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.
See MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/20/2025 02:20 PM - It Cannot Be Edited

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: TEHACHAPI MANOR
FACILITY NUMBER: 157206846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(h)(6)
87465 (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview conducted, Licensee confirm staff have been administering R1’s medication Donepezil Hcl 5mg 2/10/25. Licensee and LPA confirmed Donepezil Hcl 5mg is not recorded on the Centrally Stored Medication Record (Lic 622), which poses/posed a potential health and safety risk for the person in care.9
POC Due Date: 02/26/2025
Plan of Correction
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Staff immediately record R1’s medication Donepezil Hcl 5mg in Lic 622. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
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