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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209332
Report Date: 09/15/2026
Date Signed: 09/15/2026 01:04:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2026 01:04 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:LEGACY ADULT CARE LLCFACILITY NUMBER:
107209332
ADMINISTRATOR/
DIRECTOR:		MAKARYAN,HRIPSIMEFACILITY TYPE:
740
ADDRESS:2348 E HARVARD AVENUETELEPHONE:
(559) 293-3955
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 6CENSUS: 5DATE:
09/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee, Hripsime "Kristina" MakaryanTIME VISIT/
INSPECTION COMPLETED:
01:11 PM
NARRATIVE
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On 9/15/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced annual visit. LPA met with Care Givers, Kelly Gordon and Elizabeth Flores, explained reason for visit and was permitted entry into the facility. License/Administrator was contacted and arrived a short time later. A tour of the facility was completed inside and out. A health and safety check was completed on residents in care. There were 5 of 5 residents present during todays visit. Residents observed in common areas, in the yard and in their rooms. The facility is a 3 bedroom, 1 bath. Bedroom 2 and 3 are shared bedrooms. Care Tool was not accessible or used during this visit.

Pathways and doors were clear and free from obstruction inside the facility. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last purchased 07/02/23 and observed to be fully charge. Fire extinguisher was last serviced by fire department 05/11/26. Last fire drill on conducted on 06/02/2026. 3 of 3 resident rooms observed to have the required furnishings and with adequate lighting. Chemicals and medications were located in locked cabinets/closets. LPA observed sufficient seating under covered patio areas.

A sample of resident and staff files reviewed. Required documentation observed in 3 staff files (CPR/1st aid, personal record, health screening/TB, criminal record statement, fingerprint clearances and training)and 2 resident files (admission agreements, needs and services plans, medical assessments and TB, consent forms, id/emergency information, safeguarding valuables and personal rights) present and reviewed.

CONT...

See Moua
Mary Garza
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
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
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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332
VISIT DATE: 09/15/2026
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CONT...

The following issues were observed during today’s visit: At 9:29 am LPA observed a blue razor knife in the living room sitting on a table near the fireplace. Knife was observed unlocked and accessible to residents in care. Review of 2 of 2 resident files reviewed disclosed a potential risk to residents in care.

Resident files reviewed and interview with licensee, disclosed 3 of 5 residents have a restricted health condition without an exception.

Facility does not have a complete emergency and disaster plan. The plan is has inaccurate transportation information, information locations are marked TBD and not showing the location, utility shut off locations are blank, temporary shelter location does not have a location listed outside the immediate area.



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 and potential risk to the health, safety and/or personal rights of residents in care.

LPA requested the following documents to be submitted to CCL by 09/18/2026: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), 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, Kristina. A plan of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to Licensee.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/15/2026 01:04 PM - It Cannot Be Edited


Created By: Mary Garza On 09/15/2026 at 11:57 AM
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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2026
Section Cited
CCR
87309(a)

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87309 Storage Space and Access (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.
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Licensee stated they will provide a plan of correction in writting. Staff training will be completed and an in-serivce sign in sheet will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that at 9:29 am, LPA observed a blue razor knife in the living room sitting on a table near the fireplace. Knife was observed unlocked and accessible to residents in care. Review of 2 of 2 resident files reviewed disclosed a potential risk to residents in care. This poses an immediate health, safety and or personal rights risk to residents in care.
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Type B
09/29/2026
Section Cited
CCR87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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A training will be completed by the LVN for all staff and requests for exceptions will be provided to CCL by POC date.
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This requirement was not met as evidence by: records reviewed and interviews conducted. The Licensee did not comply with the section cited above in that 3 of 5 residents have a restricted health condition without an approved exception. This poses a potential health, safety and or personal rights risk to residents in care.
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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: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/15/2026 01:04 PM - It Cannot Be Edited


Created By: Mary Garza On 09/15/2026 at 12:27 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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2026
Section Cited
HSC
1569.695(a)

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1569.695 Emergency Plans
(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:...
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Licensee stated the plan will be updated with corrected information and will be sent to CCL by POC date as proof of correction.
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This requirement was not met as evidence by: records reviewed. The licensee did not comply with the section cited above in that the facility does not have a complete emergency and disaster plan. The plan is has inaccurate transportation information, information locations are marked TBD and not showing the location, utility shut off locations are blank, temporary shelter location does not have a location listed outside the immediate area. This poses a potential health, safety and or personal rights risk to residents in care.
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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: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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