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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 07/08/2024
Date Signed: 07/08/2024 11:50:52 PM


Document Has Been Signed on 07/08/2024 11:50 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
SIERRA CASCADE AC/SC, 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) 345-4929
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:49CENSUS: 34DATE:
07/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Care Coordinator Luijean De CastroTIME COMPLETED:
05:00 PM
NARRATIVE
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On 7/8/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced. LPA met with Care Coordinator Luijean De Castro.

While touring the facility LPA observed the facility to be at an uncomfortable temperature. LPA asked Care Coordinator Luijean De Castro the temperature. Care Coordinator Luijean De Castro stated the temperature is controlled by the main office. Thermostat was blank and when LPA asked Care Coordinator Luijean De Castro to open the locked thermostat they did not have access and stated someone from the main office was coming to open. By the time this report was completed no one had arrived to unlock the thermostat box.
Citation was issued under Title 22, Division 6, Chapter 8.

LPA observed R3 to have full bed rails and is not on hospice. Care Coordinator Luijean De Castro stated R3 was taken off hospice 4/14/24. Citation was issued under Title 22, Division 6, Chapter 8.


Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Care Coordinator Luijean De Castro.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
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 07/08/2024 11:50 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2024
Section Cited
CCR
87303(b)

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87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times.
This requirement is not met as evidenced by:

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Duplicate key will be made to be kept at the facility. Care Coordinator Luijean De Castro will have someone come out and look at the AC. Verification will be provided to LPA.
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Based on observation & interview, the licensee did not comply with the regulation listed above. LPA asked Care Coordinator Luijean De Castro to verify temperature in the facility. Care Coordinator Luijean De Castro showed LPA a screen on their phone but did not have access to the thermostat. Pictures provided to LPA show a higher temperature than thermostat is set at.
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Type A
07/09/2024
Section Cited
CCR87608(5)(B)

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87608 Postural Supports
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Bed rails will be removed and verification will be sent to LPA.
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Based on observation & interview, the licensee did not comply with the regulation listed above. R3 does not have a current hospice plan on file showing doctors orders requesting full bed rails.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2