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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 05/28/2021
Date Signed: 07/14/2021 11:01:23 AM

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:KUMAR, HARMESH PH.D.FACILITY TYPE:
740
ADDRESS:175 W. SIERRA AVE.TELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:49CENSUS: 34DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator, Susan SundariTIME COMPLETED:
05:11 PM
NARRATIVE
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On 05/28/2021, Licensing Program Analysts, M. Garza and M. Medina arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA's were greeted by Cintun Pok. LPA's were permitted entry into the facility. Administrator, Susan Sundari arrived a short time later. LPA observed a central entry point but did not see a supply of hand sanitizer or sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in common area watching television, down hallways, outside and in rooms.

Mitigation plan was not on file. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA's toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Two staff observed not wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed a supply of PPE and resident medications. Sinks stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are not found to be in compliance. Technical Advisory and citation was issued during todays inspection. Exit interview completed with Administrator.

A copy of this report was sent via email for signature. A delivered and read receipt was sent as confirmation of receipt.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff was not wearing face masks which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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Staff was immediately asked to put on face masks and complied. Staff to be trained on face coverings. Proof of training will be provided to CCL no later than 6/18/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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