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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 04/29/2025
Date Signed: 04/29/2025 12:49:56 PM

Document Has Been Signed on 04/29/2025 12:49 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:TAR SPRINGS HOME CAREFACILITY NUMBER:
157209196
ADMINISTRATOR/
DIRECTOR:		TELMO, SOCORRO ANNFACILITY TYPE:
740
ADDRESS:2804 TAR SPRINGS AVENUETELEPHONE:
(661) 831-3430
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 6DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Licensee/ Administrator (L1) Socorro Ann TelmoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 04/29/25, 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 Licensee/ Administrator (L1) Socorro Ann Telmo. LPA toured facility with L1. All five residents were present during the 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. Washer observed operating during visit. Chemicals observed locked under kitchen sink and garage cabinet. Knives stored and locked in kitchen drawer. Medications observed stored and locked under kitchen counter. Residents’ MARS and Centrally Stored Medication Records were reviewed. Medications were checked. Fire extinguisher was observed with purchased date of 03/01/25. LPA observed 2-day perishable food was observed and 7 day non-perishable food. Freezer temperature maintained at 0 degree F and refrigerator temperature maintained at 32 degrees F. Extra linens were observed. 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 at 110.7 and 110.1 degrees F in master bedroom bathroom and 107.4 degrees in hall bathroom. Outside of facility toured and observed free of debris. Adequate outdoor seatings observed available for the residents. A sample of staff and all residents’ files were reviewed. Carbon monoxide and smoke detector operational during visit.

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

Exit Interview conducted. LPA received copies of: Lic 308, Lic 500, Lic 610E, current Administrator certificate, and current liability insurance. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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 4
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 04/29/2025 12:49 PM - It Cannot Be Edited


Created By: Mai Yang On 04/29/2025 at 12:04 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: TAR SPRINGS HOME CARE
FACILITY NUMBER: 157209196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation and interviews conducted, the licensee did not comply with the section cited above when LPA and L1 observed R2’s medication Multivitamin stored unlock on television stand in resident’s room and R4 medication Milk of Magnesia stored unlock on dresser in the resident’s room which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 04/30/2025
Plan of Correction
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Staff immediately removed R2 and R4’s medication to locked kitchen drawer. POC cleared during visit.
Type A
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 R1 medication Levothyroxine 75mcg and Donepezil Hcl 5mg in the morning ON 04/29/25 at 08:00am, and did not record in the resident’s MARs, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 04/30/2025
Plan of Correction
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S1 will 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 04/30/25.
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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/29/2025 12:49 PM - It Cannot Be Edited


Created By: Mai Yang On 04/29/2025 at 12:05 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: TAR SPRINGS HOME CARE
FACILITY NUMBER: 157209196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
87458(c)(1)(A) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A)Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, R1 and R2 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee will submit proof of TB result or X-ray results for R2 and R3 to Fresno CCL by POC due date 05/19/25.
Type B
Section Cited
CCR
87608(a)(3)
87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to
verify the order.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on interview conducted, observation, and records reviewed, R1 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee shall obtain doctor orders for R1 indicating the need for half bed rail and if physician do not indicate the need for half bed rail, hail rail must be removed by POC due date 05/05/25.
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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4