107203505-5-17-2024-24-AS-LPAT-D5CUCH-20240517152756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:28:11 PM

Document Has Been Signed on 05/17/2024 03:28 PM - 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 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: 38	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Luijean De Castro, Care Coordinator		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Care Coordinator Luijean De Castro (CC) and explained the purpose of the visit. Facility was toured with CC. During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring between 105.1 to 114.3 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed that refrigerator, was kept at a 41.4 degrees F, and the freezer at -4 degrees F, well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized, and had 7 days of non-perishable food. No expired food was observed. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Perimeter fence is maintained locked. First aid kit located in the medication room found to contain required items. Fire Extinguishers are located throughout the facility and were serviced in 5/17/2024. Smoke and Carbon Monoxide detectors are tested annually with Johnson Controls Fire Inspection company. LPA reviewed and obtained a copy of the last inspection report conducted on 3/26/2024.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 05/17/2024

NARRATIVE

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LPA conducted resident and staff file reviews and interviews. Administrator’s re-certification was confirmed to be in active status. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with CC, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/24/2024 : Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 05/17/2024 03:28 PM - 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of broken dresser drawer in room 8. LPA observed missing dresser drawers and the closet door that is not easily moved becuase it gets stuck on the floor in room 17 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Licensee will replace both dresser and replace closet door with closet curtains. Licensee will send photo verification to this LPA by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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