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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:54:23 PM


Document Has Been Signed on 11/29/2023 03:54 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 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: 39DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Sundari Susan KendakurTIME COMPLETED:
12:45 PM
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On 11/29/23 at 8:10 AM, Licensing Program Analyst (LPA) Miriam Flores arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee, Sundari Susan Kendakur arrived minutes later.

LPA toured the inside and outside of the facility. Smoke and carbon monoxide detectors tested and operational. On building #2 water measured at 111.8 degrees F. Sufficient 2-day perishable and 7-day non-perishable food supply observed. Chemicals observed in locked storage closet near their activity room. Medications observed locked in the main office.

Due to time constrains, LPA will return for an Annual continuation inspection to complete the Inspection Tool. Other observations made during this visit and will be addressed in annual continuation inspection.

The following updated forms are to be submitted to CCL by 12/06/2023: LIC500, LIC610D, LIC9020, LIC400, LIC402, Administrator’s certificate.

Exit interview conducted. A copy of this report was given to Licensee, Sundari Susan Kendakur, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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