107203505-5-10-2021-24-AS-MHON-C2WKUE-20210511081237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 05/10/2021
Date Signed: 05/10/2021 10:48:33 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
10/09/2020 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20201009084600

FACILITY NAME:	SIERRA VILLA REST HOME		FACILITY NUMBER:	107203505
ADMINISTRATOR:	KUMAR, HARMESH PH.D.		FACILITY TYPE:	740
ADDRESS:	175 W. SIERRA AVE.		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	49	CENSUS: 35	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	06:41 PM
MET WITH:	Administrator, Susan Sundari		TIME COMPLETED:	08:12 PM

ALLEGATION(S):

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Facility staff hit resident while in care.

INVESTIGATION FINDINGS:

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On 5/10/2021 Licensing Program Analyst (LPA) M. Garza conducted complaint investigation visit with the facility via tele-confrence to discuss complaint findings. Due to COVID 19 and pre-cautionary measures LPA identified self and discussed the purpose of the call with Administrator, Susan Sundari. Allegation was reviewed with Susan.

The Department investigated the above allegation. Based on interviews or residents, staff, records review of Physician reports, staff schedules, staff and resident rosters, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above found to be is found to be UNSUBSTANTIATED. Exit interview completed and appeal rights given.

A copy of the complaint investigation report was sent via email for signature. A delivery and read receipt were sent to serve as confirmation of reciept.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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