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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209543
Report Date: 04/06/2026
Date Signed: 04/06/2026 03:37:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2026 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20260206133817
FACILITY NAME:ELIM PLACEFACILITY NUMBER:
107209543
ADMINISTRATOR:CEBALLOS, MARIAFACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(650) 776-2280
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:44CENSUS: 33DATE:
04/06/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Maria CeballosTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to lack of supervision, resident hit another resident
INVESTIGATION FINDINGS:
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On 4/06/2026, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct a subsequent complaint inspection. LPA met with Administrator Maria Ceballos and announced the purpose of the visit. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observations, interviews conducted and records reviewed, due to lack of supervision, resident hit another resident. Incident happened during dinner when caregivers were busy getting meals from kitchen and assisting residents with feeding.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. An exit interview was conducted with Administrator. A copy of this report, including appeal rights was provided to Administrator, whose signature on this form confirms receipt of this document.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20260206133817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ELIM PLACE
FACILITY NUMBER: 107209543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2026
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement was not met as
evidenced by:
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Administrator agrees to develop a plan for preventative measures and complete staff training and submit records when completed.
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Based on record review and interviews due to lack of supervision facility failed to prevent resident being hit by another resident
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2