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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209223
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:14:39 PM

Document Has Been Signed on 04/22/2025 02:14 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:PLEASANT HOME CAREFACILITY NUMBER:
157209223
ADMINISTRATOR/
DIRECTOR:		ASAWADILOKCHAI, YANINEEFACILITY TYPE:
740
ADDRESS:10609 PLEASANT VALLEY DRIVETELEPHONE:
(714) 655-6454
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 3DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Licensee/ Administrator Yaninee via telephone and staff Patcharee Wolff. TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 04/22/25, 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 staff Patcharee Wolff. Licensee/ Administrator Yaninee Asawadilokchai was called and stated unable to attend meeting. Licensee authorized staff to receive and sign report. LPA toured facility with S1. All three 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. Medications, knives, sharps, laundry detergent were observed locked in kitchen pantry. Residents’ MARS and Centrally Stored Medication Records were reviewed. Medications were checked. Fire extinguisher was observed with a service date of: 03/12/25. LPA observed 2-day perishable food was observed and 7 day non-perishable food was not observed. Freezer temperature maintained at -3 degree F and refrigerator temperature maintained at 37 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 range at 114.7 degrees F in hall bathroom and 116.2 and 117.9 degrees F in master 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.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 14
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 14
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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223
VISIT DATE: 04/22/2025
NARRATIVE
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Technical Support Program (TSP) assistance was offered. Staff will inform Administrator/ Licensee and will make a decision and reach out the department regarding acceptance.

A deficiency is being cited on the attached 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: 04/28/25. LPA received copy of Lic 500, Lic 9020, and current liability insurance. The following updated forms were requested: Lic 308, and Lic 610E. A copy of this report and appeal rights was provided to staff , whose signature on this form confirms receipt of this report and to Licensee via telephone.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:45 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)
87405(d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above due to the amount of citations Administrator is not meeting the requirements of this regulation, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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2
3
4
Licensee will submit a plan in writing on how the Administrator will meet the qualifications in this regulation from 1 to 7 by POC due date 04/23/25.
Type A
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 observation, records reviewed, and interview conducted, all the resident’s medication were administrated daily. Medication was checked and MAR was reviewed, all residents’ medications were not administered as instructed by physician which poses/posed an immediate health and safety risk for the person in care.

POC Due Date: 04/23/2025
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include
medication is administered as prescribed, and medication is record on MAR correctly to Fresno CCL office by POC due date 04/23/25.
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: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:46 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(a)(6)
87468(a)(6) To make choices concerning their daily lives in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interviews conducted, upon arrival the hall food pantry was locked, which poses/posed a potential health and safety and personal rights risk to the resident in care.

POC Due Date: 04/23/2025
Plan of Correction
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3
4
Licensee shall ensure that resident is able to access food pantry and food pantry is unlock by POC due date 04/23/25.
Type A
Section Cited
CCR
87555(b)(25)
87555(b)(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interviews conducted, at 10:46AM , laundry detergent were observed stored and locked in food pantry with food supplies, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 04/23/2025
Plan of Correction
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Licensee shall chemicals are stored in a separate from the food by POC due date 04/23/25.
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: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:47 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, perishable foods were observed, poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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3
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Staff immediately disregarded expired food. POC cleared during visit.
Type A
Section Cited
CCR
87309(a)
87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked
storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted, staff was using a knife to cook then approximately at 12:19PM left to the room to assist R1 leaving knife on the kitchen counter unattended and unlock, poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Staff immediately removed knife and locked in food pantry. 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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:48 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and records reviewed, R1’s medication Morphine Sulf 100 mg/5ml was not record in the resident’s MAR. R2’s medication Glipizide 5mg and Vitamin @ 1.25 mg were record administered daily for the month of April 2025 and not observed in the facility. At approximately 10:58AM, LPA observed R3’s MARs, staff record all R3’s evening medications were all administered, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 04/23/2025
Plan of Correction
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R1 and R2’s MAR recording all of resident’s current medications will be submitted to the Fresno CCL by POC due date 05/02/25. S1 shall have in-service training on medications which will include administering and documentations by POC due date 05/02/25.
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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:49 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
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 and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview conducted, observation, and records reviewed, all the resident’s current medications were not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

POC Due Date: 05/02/2025
Plan of Correction
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2
3
4
Lic 622 for all the residents shall be completed and submitted to the Fresno CCL by POC due date 05/02/25.

Type B
Section Cited
CCR
87465(i)
87465 (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview conducted, observation, and records reviewed, R2 and R3 destructed medications were stored in food pantry, not record and not destructed, poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 05/02/2025
Plan of Correction
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3
4
Medications destruct for R2 and R3 will be record and properly destruct by POC due date 05/02/25. Destructed record will be submitted to Fresno CCL by 05/02/25.

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: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:51 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews conducted, Administrator works only on Saturday and Sunday and S1 is staff that works Monday through Friday, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
A written statement of how Licensee will meet regulations which will include how and when Administrator will be present at the facility. Written statement will be submitted to the Fresno CCL by POC due date 04/25/25.
Type B
Section Cited
CCR
87555(b)(26)
87555 (b)(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview conducted, 7 day nonperishable foods were not observed, poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Licensee shall ensure the facility have a minimum of 7 day nonperishable food in the facility by POC due date 04/25/25.

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: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 11 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:52 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, R1 is on hospice care and was observed lying bed using a hospital bed with full rail 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: 04/25/2025
Plan of Correction
1
2
3
4
Licensee shall obtain doctor orders for R1 who’s currently receiving hospice care that specific the need for full bed rails. If R1 is not eligible for hospice evaluation to retain a full bed rail, seek physician order for half bed rails and remove full bed rails. Order shall be obtained and submitted to the Fresno CCL by POC due date 04/25/25.
Type B
Section Cited
CCR
87463(b)
87463(b) The reappraisal shall document significant changes in the resident’s physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview conducted, observation, and records reviewed, R3 is bedridden, and no reappraisal was completed for change of condition, poses/posed a potential health and safety and personal rights risk to the resident in care.

POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
R3 reappraisal will be completed and submitted to the Fresno CCL by POC due date 04/25/25.
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: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 01:54 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
87555(b)(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interviews conducted, at 10:46AM , laundry detergent were observed stored and locked in food pantry with food supplies, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 04/23/2025
Plan of Correction
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Licensee shall chemicals are stored in a separate from the food by POC due date 04/23/25.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 04/22/2025 02:14 PM - It Cannot Be Edited


Created By: Mai Yang On 04/22/2025 at 02:10 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.45
HSC 1796.45 Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to
employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews conducted, S1 did not have a TB result, which poses a potential risk to the health and safety of the residents.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee shall ensure all staff have a TB result on file prior or within 7 days after employment. S1 and S2 TB result shall be submitted to the Fresno CCL office by POC due date 05/02/25.
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
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 14 of 14