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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 04/20/2022
Date Signed: 04/20/2022 07:19:14 PM

Document Has Been Signed on 04/20/2022 07:19 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
CCLD Regional Office, 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: 43DATE:
04/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:07 PM
MET WITH:Administrator, Sundari Susan KendakurTIME COMPLETED:
06:38 PM
NARRATIVE
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On 4/20/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced complaint visit. LPA was met by Direct Care Staff, Annie Togonon. Administrator, Susan Kendakur was contacted and arrived a short time later. LPA toured the facility inside and out and completed a Health and Safety check on residents in care. Residents observed in common areas, in rooms and in office. LPA explained reason for visit with Administrator.

During the visit the following was found and noted on a case management visit:
1 of 2 staff observed not wearing a face mask and infection control practices were not being followed. Bedroom #3 was observed with no mattress. Bed in room was not occupied by a resident at this time. Food in the kitchen refrigerator/freezer was opened and not marked with dates, LPA observed pests in freezer on top shelf freezer door, tops of kitchen refrigerators observed being dirt and needing cleaning, a puddle of dirt mop water was observed at the back of the building of sidewalk, side yard of facility observed with debris and overgrown weeds, freezer in storage room observed full of frost bite/ice, refrigerator in storage room observed with molded heads of cauliflower/cabbage/lettuce, refrigerator in need of cleaning, door with a hole in it observed against side fence that maintenance stated "had been there for awhile".

These issues pose a Health and Safety risks to resident in care. Deficiencies cited on the attached LIC 809D per Title 22. Exit interview completed. Appeal Rights given.

Due to COVID precautionary measures reports will be emailed to: anjaleoni@icloud.com. A delivered and read receipts serving as confirmation.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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Document Has Been Signed on 04/20/2022 07:19 PM - It Cannot Be Edited


Created By: Mary Garza On 04/20/2022 at 05:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
87555(b)(27)

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87555 General Food Service Requirements
All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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Administrator to provide copy of pest control receipts for last 3 months and provide training with staff on regulation. A sign in sheet to be completed and a copy of training material to CCL by POC date.
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This requirement was not met as evidence by: Through LPAs observations. LPA observed pests in the kitchen freezer on the top door shelf. This posses a potential Health and Safety risk to residents in care.
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Type B
04/29/2022
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a)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 was not met as evidence by: Through LPAs observations.
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Per Adminsitrator refridgerators/freezers to be cleaned out and pictures provided to LPA. Debris will be cleaned by gardener and training to be completed on regulations with staff. Administrator to provide training material and sign in sheet to CCL by POC date.
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LPA observed food in kitchen refrigerator/freezer opened/not marked with dates, refrigerators needing cleaning, puddle of dirty mop water along sidewalk, side yard with debris and overgrown weeds, freezer with frost bite/ice and molded heads of cauliflower/cabbage/lettuce, broken door against side fence. These issues pose a potential Health and Safety risk to residents in care.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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