157206875-4-4-2025-24-AS-MYAG-DFELJ8-20250404084731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206875
Report Date: 04/02/2025
Date Signed: 04/04/2025 08:47:43 AM

Document Has Been Signed on 04/04/2025 08:47 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:	DEVOTED HOME CARE, LLC		FACILITY NUMBER:	157206875
ADMINISTRATOR/ DIRECTOR:	AGUIL, AMILYN		FACILITY TYPE:	740
ADDRESS:	10106 COBBLESTONE AVENUE		TELEPHONE:	(661) 858-0862
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Administrator Petro Crisostomo		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/02/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and met with Administrator(A1) Petro Crisostomo. Upon arrival audio video camera monitor observed in the common area. LPA toured facility with A1. All five residents were present during the inspection. Three residents were observed sitting in the living room and two in the bedrooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. All residents’ files were reviewed to have required documents. Medications were checked and observed unlocked medication cart and kitchen shelf. Residents’ MARS and Centrally Stored Medication Records were reviewed. Fire extinguisher was observed with a service date of:03/03/25. Last fire drill completed on 01/10/25. An adequate supply of perishable and non-perishable food was observed. Freezer temperature maintained at 0 degree F and refrigerator temperature maintained at 44 degrees F. Knives observed locked in kitchen drawer. LPA observed over-the-counter medications stored in First Aid box unlock on the kitchen wall. Washer and dryer observed functional and operational during visit. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested range at 118.9 and 117.7 degrees F in master bathroom and 118.9 degrees F in hall bathroom.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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 8

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)

Page: 2 of 8

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: DEVOTED HOME CARE, LLC	FACILITY NUMBER: 157206875
	VISIT DATE: 04/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Outside of facility toured and observed free of debris. Side exit observed with no obstructions. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of staff files were reviewed to have all required documents. Carbon monoxide and smoke detector operational during visit.

Technical Support Program (TSP) assistance was offered to Administrator. Administrator will make a decision and reach out the department regarding acceptance.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421IM.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/08/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 04/04/2025 08:47 AM - 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: DEVOTED HOME CARE, LLC	FACILITY NUMBER: 157206875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

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
1 2 3 4	Based on records review and observation, R1’s medication Vitamin D3 5,000 unit and R2’s medication Stimulant Laxative Plus was not administered as directed by physician, which poses an immediate health and safety risk for the person in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Administrator agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 04/03/25.

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when LPA and Administrator observed at approximately 1:34PM, over-the-counter medications stored in First Aid box unlock on kitchen wall which poses an immediate health, safety or personal rights risk to person in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Staff immediately removed over the counter medications into locked medication shelf. POC cleared during 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.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 04/04/2025 08:47 AM - 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: DEVOTED HOME CARE, LLC	FACILITY NUMBER: 157206875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87468.1(a)(2)

87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted, the licensee did not comply with the section cited above when audio video camera was observed in R3’s room and audio video monitor of R3’s room observed in the common area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	The audio video camera in R3’s room and audio video camera monitor were immediately removed. POC cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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 Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 04/04/2025 08:47 AM - 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: DEVOTED HOME CARE, LLC	FACILITY NUMBER: 157206875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(d)(3)

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and records reviewed, R1’s medication Nutrafol Women’s balance was checked and accounted for. Staff did not sign on MARs that medication was administered on 04/02/25 in the morning, which poses/ posed a potential health and safety risk for the person in care.
	POC Due Date: 04/11/2025
	Plan of Correction
1 2 3 4	All staff shall be retrained in in-service training on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance rooster to CCL by POC due date 04/11/25.

Type B

Section Cited

CCR

87608(a)(5)(B)

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, R2 is receiving hospice care observing lying bed using a hospital bed with full rail with no doctor’s order. R4 was observed with full rail bed with no doctor’s order, in which poses/posed an immediate health and safety and personal rights risk to the resident in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Doctor orders for R2 for full rail bed shall be obtained if R2 is not eligible for hospice evaluation to retain full bed rails, seek doctor’s order for 1/2 bed rails and remove full bed rails by POC due date. R4’s full rail is to be removed by POC due date 04/03/25.

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 Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 04/04/2025 08:47 AM - 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: DEVOTED HOME CARE, LLC	FACILITY NUMBER: 157206875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87608(a)(5)(A)

87608(a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, R1 has a half rail bed with no doctor’s order, in which poses/posed an potential health and safety and personal rights risk to the resident in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Doctor orders for R1 for half rail bed shall be obtained or half rail shall be removed by POC due date 04/03/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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 Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 7 of 8