107203505-12-19-2023-24-AS-SPIY-CZBMPR-20240109084730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:42:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
11/09/2023 and conducted by Evaluator Miriam Flores

COMPLAINT CONTROL NUMBER: 24-AS-20231109100726

FACILITY NAME:	SIERRA VILLA REST HOME		FACILITY NUMBER:	107203505
ADMINISTRATOR:	SUNDARI SUSAN KENDAKUR		FACILITY TYPE:	740
ADDRESS:	175 W. SIERRA AVE.		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	49	CENSUS: 39	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Shannon Steele		TIME COMPLETED:	11:55 PM

ALLEGATION(S):

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Staff prohibit resident from having visits

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Miriam Flores arrived at the facility unannounced to conduct a subsequent complaint visit and deliver findings. The purpose of the visit and elements of the allegation were reviewed with Care Coordinator, Shannon Steele.

The Department investigated the allegation: Staff prohibit resident from having visits. Based on interviews conducted, file reviews and house rules the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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