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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 06/17/2020
Date Signed: 06/17/2020 12:45:41 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/22/2019 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20191022081057
FACILITY NAME:SIERRA VILLA REST HOMEFACILITY NUMBER:
107203505
ADMINISTRATOR:KUMAR, HARMESH PH.D.FACILITY TYPE:
740
ADDRESS:175 W. SIERRA AVE.TELEPHONE:
(559) 299-5579
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:49CENSUS: DATE:
06/17/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator Sundari "Susan" KendakurTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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5
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9
Facility staff failed to monitor resident's changing condition.
Resident was not allowed to have visitors.
Facility staff is coercing resident to not have contact with visitors.
Facility staff are retaliating for filing a complaint.
Facility staff are failing to ensure that the resident's medication dosage is accurate.
INVESTIGATION FINDINGS:
1
2
3
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5
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9
10
11
12
13
An unannounced Complaint call was conducted on the date & during the times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA spoke with Assistant Administrator (AA) Sundari "Susan" Kendakur.

Staff interviewed. Resident records reviewed.

Staff denied observing resident vomiting or being sent to ER. Resident 1 (R1) is no longer residing at the facility. LPA not able to contact R1. There is no documentation to show resident was vomiting or was sent to ER around the time of the investigation.

Continued. See page 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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-20191022081057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505
VISIT DATE: 06/17/2020
NARRATIVE
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Continued from Page 1.

Staff denied preventing R1 from having visitors. R1 is no longer residing at the facility. LPA not able to contact R1. There is no documentation to show R1 was not allowed to have visitors around the time of the investigation.

Staff denied coercing R1 not to have contact with visitors. R1 is no longer residing at the facility. LPA not able to contact R1. There is no documentation to show that staff coerced R1 not to have contact with visitors around the time of the investigation.

Staff denied that there was retaliation for a complaint being filed. R1 is no longer residing at the facility. LPA not able to contact R1. There is no documentation to show staff retaliation for a complaint being filed around the time of the investigation.

Staff denied giving inaccurate medication dosages. R1 is no longer residing at the facility. LPA not able to contact R1. There is no documentation to show inaccurate medication dosages around the time of the investigation.

The Department has investigated the above allegations. Although the above allegations may have happened or are valid, there is not a preponderance of evidence at this time to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Assistant Administrator Sundari "Susan" Kendakur. Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2