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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 02/01/2024
Date Signed: 02/01/2024 09:28:33 AM


Document Has Been Signed on 02/01/2024 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SIERRA VILLA REST HOMEFACILITY NUMBER:
107203505
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:175 W. SIERRA AVE.TELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:49CENSUS: 41DATE:
02/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Sundari Susan KendakurTIME COMPLETED:
09:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) M. Flores conducted an unannounced Case Management visit. LPA met with Care coordinator Luijean “Jean” De Castro Abraga and explain the purpose of the visit.

During the course of file reviews, it was found that the facility has not submitted incident reports to the Department per Title 22 Regulations. A written report shall be submitted to the licensing agency of any incidents which threatens the welfare, safety, or health of any resident within seven days of the occurrence of any of the events.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Care coordinator Luijean “Jean” De Castro Abragan and a copy of this report along with appeals right provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 2


Document Has Been Signed on 02/01/2024 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department ...including, but not limited..: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven day. Any incident which threatens the welfare, safety or health of .. any resident.

This requirement is not met as evidenced by: Based on interview and record review.
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Licensee will submit a copy of the training log on Reporting Requirements to the Department by 02/02/24.

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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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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