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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 06/09/2026
Date Signed: 06/09/2026 05:57:02 PM

Document Has Been Signed on 06/09/2026 05:57 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:UNION VILLAFACILITY NUMBER:
157206907
ADMINISTRATOR/
DIRECTOR:		MONTIANO, NANCYFACILITY TYPE:
735
ADDRESS:1102 S. UNION AVE.TELEPHONE:
(661) 323-0768
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 89CENSUS: 52DATE:
06/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Yvonne Aggasid, Office AssistantTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daiquiri Boyd and Licensing Program Manager (LPM) Shawna Doucette arrived unannounced to conduct the Annual inspection. LPA explained the purpose of the visit and allowed entry into facility office by care staff. Staff called Administrator, Nancy Montiano (AD) who spoke with LPA and AD stated that she was sick and could not make the visit due to illness. Office Assistant (OA) Yvonne Aggasid would be available to assist LPA on this day.
Facility tour and inspection revealed the following:
LPA/LPM requested Infection Control, but document could be produced. LIC610 Emergency Disaster Plan for Residential Care was posted and signed off 2/27/2024. LIC610D was reviewed and found to not have complete information. Administrator Certificate expired 6/15/2025, online review of certification shows it was submitted 6/9/25 and still shows pending.
LPA/LPM reviewed 3 client files. Client files were found to be missing updated Medical Assessments, some files were missing re-appraisals, elderly clients were missing correct LIC602A, files were missing restricted health care plans.
R1 had a medication that was found to be expired. LPA/LPM located a home health folder for R1 with resident information inside, no care plan was found in R1 file. LPM called home health in regard to the file and found that R1 was on home health 2/3/26 to 2/25/26 after being released from the hospital for wound care. For R1, caregiver/office staff had no knowledge that R1 was on home health or that R1 had wounds.
R1 and R2 had no restricted health care plan for existing condition. R1 and R2 did not have reappraisals on file. Last LIC602 was dated in 2023 for 3 out of 3 residents. 27 out of 52 residents were over the age of 60 and do not have the correct LIC602A on file. There is no Age Exception on file.
(contined on next page)
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2026
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: UNION VILLA
FACILITY NUMBER: 157206907
VISIT DATE: 06/09/2026
NARRATIVE
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Resident rooms contained required furnishings and lighting. LPA/LPM observed room 2 to have a sink that has broken and is not affixed to the wall. Room 2 has no bathroom door. LPA's tested the hot water in four resident rooms; rooms 2, 7, 41, and 45, with one of the four rooms measuring 99.1 F. All 4 room toured had dirty sheets or dirty cloth mattress cover. Old blood stains were observed on all bedding and pillowcases. Live bedbugs were observed in room 2 on the mattress. In room 2, resident had his portable radio wired directly into the outlet in the bathroom, wiring was taped into plug with clear packing tape. Various resident rooms throughout the facility were observed to be missing screens. All rooms toured were not clean. Bedding and bathroom towels were dirty. None of the resident bathrooms had floor rugs/bath mats and facility was using towels on the floor. LPA/LPM observed alive and dead bugs in all rooms toured. None of the rooms had central heating or air conditioning, only some rooms have portable heat/coolers, and there is no way to monitor room temperature. Room 21 has a window with broken glass, covered with cardboard.
The kitchen was toured and LPA/LPM observed sufficient supply of food per regulatory requirements. Sharps/knives were not properly stored.
LPA/LPM were told by OA that she did not have the key to a room off of storage area, LPA couldn't inspect.
Medications are centrally stored and locked however LPA noted there was a resident prescription unlocked and accessible in the office on the desk. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Medications were pre-poured for at least 3 days for all residents. No medication destruction log is being kept. Medications to be destroyed are being kept in a large coffee can on the floor of the medication room and are all loose in the can. Prescription creams were found in a sandwich bag with a medication label attached that did not match what was in the bag.
Fire Extinguishers are located throughout the facility and observed service date of 3/28/26 by Jorgensen Co.
Due to time constraints, additional citations will be written from this report, at a later date.
Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.
An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and will be provided to OA.
LPA is requesting the following documents be submitted to the Fresno CCL office by 06/23/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2026 05:57 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 06/09/2026 at 05:04 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 1 out of 4 resident rooms, resident radio had no plug and was wired directly to electrical plug and secured with clear packing tape, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2026
Plan of Correction
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Facility to have all plugs properly secured and no raw wires inserted into electrical outlets.
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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2026 05:57 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 06/09/2026 at 05:04 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 4 out of 4 resident rooms where bed bugs, roaches, and beetles were observed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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Facility shall clean up all dead bugs and submit a plan for the extraction of pests.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 multiple resident rooms there were broken, torn or no window screens which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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Facility to repair or replace all missing, torn or broken screens.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2026 05:57 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 06/09/2026 at 05:04 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 1 out of 4 resident rooms, room 41, water temperature measured 99.1 F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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Facility to adjust the hot water heater to a level within regulation of 105-120 degrees F.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 4 out of 4 resident rooms the bedding and towels were dirty or worn, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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Facility bedding and towels needs to be clean at all times and have a necessary supply of extra linen on hand to meet the requirement.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2026 05:57 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 06/09/2026 at 05:04 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above and was found that facility does not have a regular supply of hygiene items to meet client needs in all cases which poses/posed a potential health, safety or personal rights risk to persons in care. Observed there to be 7 pads, 1 men's deoderant, 2 packs of toothbrushes, 4 tubes of toothpaste, for 52 residents.
POC Due Date: 06/23/2026
Plan of Correction
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Facility to keep a supply of hygiene and personal care products for resident use.
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 27 out of 52 residents, assessments were not completed since 2023 or on the correct form LIC602A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2026
Plan of Correction
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4
Facility shall schedule residents to get a Medical Assessment utilizing the LIC602A.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
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