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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203448
Report Date: 07/24/2026
Date Signed: 07/24/2026 03:35:14 PM

Document Has Been Signed on 07/24/2026 03:35 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:JORDETH SENIOR CARE HOMEFACILITY NUMBER:
547203448
ADMINISTRATOR/
DIRECTOR:		MANCILLA, DAVILYN TANTAYFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 5CENSUS: 3DATE:
07/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Davilyn MancillaTIME VISIT/
INSPECTION COMPLETED:
03:43 PM
NARRATIVE
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On 07/24/26 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Licensee/Administrator, Davilyn Mancilla explained reason for visit and was permitted entry into the facility. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 2 residents present during time of visit.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Carbon monoxide detector was present and operational at time of visit. Fire extinguisher last serviced 07/20/2026. Last fire drill on conducted on 07/06/2026. Resident rooms observed to have the required furnishings and with adequate lighting. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: Facility was having work done to the roof and CCL was not notified. 1 of 1 staff file reviewed did not have the required annual training completed. Facility sketch does not identify assembly points/points. Transportation needs and evacuation procedures are not appropriately reflected. Process for communicating with others is not listed. Annual training on plan is not completed. Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct risk to the health, safety and/or personal rights of residents in care.

LPA requested the following documents to be submitted to CCL by 08/07/26: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020), and a current copy of liability insurance in order to update the facility file.

Exit interview was conducted with Licensee/Administrator. A plan of correction was developed by Administrator and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to Administrator.

See Moua
Mary Garza
DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2026
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 5
Document Has Been Signed on 07/24/2026 03:35 PM - It Cannot Be Edited


Created By: Mary Garza On 07/24/2026 at 02:46 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: JORDETH SENIOR CARE HOME
FACILITY NUMBER: 547203448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. 1 of 1 staff file reviewed did not have the required annual training completed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will search for initial training records and send to CCL as proof of correction. If unable to locate, staff will complete all training and a copy of transcripts/certificates will be provided to CCL as proof of correction.

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:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 07/24/2026 03:35 PM - It Cannot Be Edited


Created By: Mary Garza On 07/24/2026 at 02:46 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: JORDETH SENIOR CARE HOME
FACILITY NUMBER: 547203448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. Facility sketch does not identify assembly points/points. Transportation needs and evacuation proceedures are not appropriately reflected. Process for communicating with others is not listed. Annual training on plan is not completed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will update the emergency and disaster plan (LIC 610E) and submit to CCL by POC date as proof of correction.
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 Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/24/2026 03:35 PM - It Cannot Be Edited


Created By: Mary Garza On 07/24/2026 at 02:46 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: JORDETH SENIOR CARE HOME
FACILITY NUMBER: 547203448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above. Upon arrival at the facility LPA observed work being done on the facility roof. Hammering and drilling observed from inside the faciilty with 2 of 3 residents being present. Work started on 7/23/26. CCL was not notified of the wor being completed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will do training for reporting requirements and provide in-service sign in sheet and training material to CCL by POC date.
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 Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
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