107203505-4-24-2025-24-AS-DBOD-DG2VKN-20250424163036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:30:57 PM

Document Has Been Signed on 04/24/2025 04:30 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/ DIRECTOR:	SUNDARI SUSAN KENDAKUR		FACILITY TYPE:	740
ADDRESS:	175 W. SIERRA AVE.		TELEPHONE:	(559) 345-4929
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY: 49	TOTAL ENROLLED CHILDREN: 0	CENSUS: 30	DATE:	04/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Juijean De Castro Abragan and Shannon Steele, Care Coordinators		TIME VISIT/ INSPECTION COMPLETED:	04:50 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) Daiquiri Boyd made an unannounced visit to the facility and was greeted by staff, who call Care Coordinator Shannon Steele to meet with LPA and complete this inspection. Care Coordinator, Juijean De Castro Abragan later came to the facility to complete this inspection with LPA as Ms.Steele had an appointment. During this visit, LPA observed resident bedrooms with dressers, closets, and beds. Some of the resident rooms have a private half bathroom. LPA observed bathrooms with hot water measuring between 105.8 to 110.8 degrees F. Resident hygiene supplies were properly stored and locked and available in a storage room inside of another room referred to as the Piano Room. 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 in a room off of the office. 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 7/02/2024. Smoke and Carbon Monoxide detectors are tested annually with Spitfire Systems, a fire inspection company. (con't on next pg.)

Sergiy Pidgirny	TELEPHONE: (559) 243-8080
Daiquiri Boyd	TELEPHONE: 559-243-8080
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/24/2025

NARRATIVE

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LPA conducted resident file review.
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 to continue this inspection at a later date.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri Boyd	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2025 04:30 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: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 out of 27 rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 2 restrooms observed which poses/posed a potential health, safety or personal rights risk to persons in care. Shower heads are continuously leaking water and there is a drain hole in the middle of the room that needs to be covered.
	POC Due Date: 05/01/2025
	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.

Sergiy Pidgirny	TELEPHONE: (559) -243-8080
Daiquiri Boyd	TELEPHONE: 559-243-8080
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2025 04:30 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: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(f)

Maintenance and Operation

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care. Trash cans with tight fitting lids must be in the bathrooms to dispose of waste.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4

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.

Sergiy Pidgirny	TELEPHONE: (559) -243-8080
Daiquiri Boyd	TELEPHONE: 559-243-8080
	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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