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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209124
Report Date: 05/29/2025
Date Signed: 05/30/2025 08:25:10 AM

Document Has Been Signed on 05/30/2025 08:25 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:GURROLA CARE HOME #6FACILITY NUMBER:
547209124
ADMINISTRATOR/
DIRECTOR:		DURAN, ANDREAFACILITY TYPE:
735
ADDRESS:343 S. MIRAGETELEPHONE:
(559) 719-7484
CITY:LINDSAYSTATE: CAZIP CODE:
93247
CAPACITY: 4CENSUS: 4DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:28 AM
MET WITH:Licensee, Mary Ellen GurrolaTIME VISIT/
INSPECTION COMPLETED:
02:41 PM
NARRATIVE
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On 5/29/2025 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced annual visit. LPA contacted Licensee, Mary Ellen Gurrola who stated staff could begin annual with Direct Support Professional (DSP), Christina. Licensee arrived some time later. LPA met with DSP, Christina Duran-Reyes, introduced self, explained reason for visit and were permitted entry into the facility. 1 resident present during visit.

LPA toured the facility. Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced on 4/11/25. Last fire drill on conducted in 5/6/25. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Refrigerator shelves missing in need of replacement. Vent exchange cover observed loose and in need of repair in hallway. Fan in bedroom #1 observed drooping and in need of replacement. Window frost in bedroom #4 observed peeling and in need of replacement. Doorway in hallway to bedrooms in need of new kick plate. Vent fan in bathroom #1 in need of trim. Water temperature in bathrooms measured over 120 degrees F. Deficiencies cited per Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D's. If not corrected the violations will have a direct and immediate risk to the health, safety and or personal rights of residents in care.

CONT...
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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 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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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: GURROLA CARE HOME #6
FACILITY NUMBER: 547209124
VISIT DATE: 05/29/2025
NARRATIVE
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CONT...

LPA requested the following documents to be submitted to CCL by 6/13/25: 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) in order to update the facility file.

Exit interview completed with Licensee, Mary Ellen and DSP, Christina. A copy of this report, deficiencies and appeal rights were discussed and provided. A plan of correction was developed by the Licensee and reviewed with the LPA.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/30/2025 08:25 AM - It Cannot Be Edited


Created By: Mary Garza On 05/29/2025 at 01:56 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: GURROLA CARE HOME #6
FACILITY NUMBER: 547209124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (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 LPA observation, the licensee did not comply with the section cited above in that the water temperture in bathroom #1 measured at 132.0 degrees F and bathroom #3 measured at 138.2 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Staff immediately turned down the water heater. A plan of action will be submitted to CCL by POC date to include, water temperature log, purchasing regulators and submitting proof to CCL as 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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/30/2025 08:25 AM - It Cannot Be Edited


Created By: Mary Garza On 05/29/2025 at 01:56 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: GURROLA CARE HOME #6
FACILITY NUMBER: 547209124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA observation, the licensee did not comply with the section cited above in that refrigerator in kitchen was missing shelves and in need of replacement. Vent exchange cover observed in hallway and in need of repair. Fan in bedroom #1 observed drooping and in need of replacement. Window frost in bedroom #4 observed peeling and in need of replacement. Doorway in the hallway to bedrooms in need of new kick plate. Vent fan in bathroom #1 in need of trim. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Administrator stated shelves for refrigerator will be purchased and repaired. A new fan will be purchased and replaced. Vent in hallway will be replaced. Trim will be added to bathroom vent. Kick plate will be replaced. Window frost will be removed and tint will be added. Pictures will be submitted 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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
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