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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208832
Report Date: 04/03/2025
Date Signed: 04/04/2025 08:43:28 AM

Document Has Been Signed on 04/04/2025 08:43 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:COBBLE STONE RESIDENTIAL HOME CARE LLCFACILITY NUMBER:
157208832
ADMINISTRATOR/
DIRECTOR:		CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:9320 COBBLE MOUNTAIN ROADTELEPHONE:
(661) 397-0885
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH: Administrator Catherine Clark TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 04/03/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit, and was greeted by staff Eleanor White. Administrator(A1) Catherine Clark was called and arrived shortly. All five residents were present during the inspection. LPA toured facility with A1. Administrator left the facility later 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. An adequate supply of perishable and non-perishable food was observed. Expired food was observed in refrigerator. At approximately 11:03AM, knives were observed stored in kitchen drawer unlock. Medications were observed locked under kitchen cabinet. MARs were reviewed and medications were checked.

Chemicals were observed locked under kitchen sink. Bathrooms were toured. Cleaning supplies were observed unlocked in under hall bathroom sink and under master bathroom sink. Hot water tested at 107.8 degrees F in hall bathroom, 111.7 and 112.4 degrees F in master bathroom. Non-skid mat was observed in hall bathroom. Master bathroom was observed with no non-skid mat. Grabbed bars were observed in all bathrooms.

All bedrooms were observed to have the required furnishings and with adequate lightening. Extra linens were observed. Fire extinguisher was observed with a purchased date of: 07/22/24. Chemical cabinet was observed unlock in laundry room and in the garage.

See MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402
DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832
VISIT DATE: 04/03/2025
NARRATIVE
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Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for residents. Sample of staff and all of the residents’ files were reviewed. Carbon monoxide and smoke detector operational during visit.

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 requested documents are to be submitted to the department by 04/09/25: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Administrator via email.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 08:43 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: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

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 Memantine Hcl 10mg, Quetiapine 25 mg, Donepezil Hcl 10mg, and Midodrine 5mg as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 04/04/2025
Plan of Correction
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R1’s medication is to be reviewed and ensure staff administered medications as directed by physician. 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 04/04/25.
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 when knives, chemicals, cleaning solutions were unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Administrator immediately locked knives, chemicals under bathroom sinks, and locked chemical cabinets. 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 MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 08:43 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: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87555(b)(8)
87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good 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, expired food was observed in the refrigerator which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Administrator immediately disposed expired food. POC cleared during visit.
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: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025

LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/04/2025 08:43 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: COBBLE STONE RESIDENTIAL HOME CARE LLC
FACILITY NUMBER: 157208832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

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
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Based on observations, records reviewed, and interviews conducted, S1 administered all the residents’ medication in the morning of 04/03/25 and did not sign in the residents’ MARs, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 04/09/2025
Plan of Correction
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S1 shall be retrained in in-service training on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance to CCL by POC due date 04/09/25.
Type B
Section Cited
CCR
87303(e)(5)
87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 no non-skid mat was observed in master bathroom, which poses/posed a potential health, safety or personal rights risk to person in care.
POC Due Date: 04/09/2025
Plan of Correction
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Proof of non-skid mat in master bathroom shall be submitted to the Fresno CCL by POC due date 04/09/25.
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 MouaTELEPHONE: (559) -65-7912
Mai YangTELEPHONE: 559-772-7402

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025

LIC809 (FAS) - (06/04)
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