107203505-9-21-2024-24-AS-SPIY-D9EMEP-20240924093305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 09/21/2024
Date Signed: 09/21/2024 01:22:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2024 and conducted by Evaluator Melinda Medina

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240412104750

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: 25	DATE:	09/21/2024
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Shannon Steele, Care Coordinator		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility placed resident on hospice without authorization

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 9/20/24, Licensing Program Analyst (LPA) M. Medina conducted a subsequent unannounced complaint visit to gather additional documents and deliver complaint findings. LPA introduced self, stated purpose of visit, and allowed entrance by direct care staff. Shannon Steele contacted by telephone and arrived a short time later to conduct visit with LPA.

This department investigated the above allegation during the investigation, This department had insufficient information regarding the allegations listed above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or disprove that the allegations occurred therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided to Administrator for facility records.

No deficiencies issued during this complaint visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 1