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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 04/20/2022
Date Signed: 04/20/2022 07:14:08 PM

Substantiated


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
08/13/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210813150239
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: 43DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Administrator, Sundari Susan KendakurTIME COMPLETED:
04:48 PM
ALLEGATION(S):
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Facility staff did not inform resident, or resident's responsible party, of change in resident's condition.
INVESTIGATION FINDINGS:
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On 4/20/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced complaint visit. LPA was met by Direct Care Staff, Annie Togonon. Administrator, Susan Kendakur was contacted and arrived a short time later. LPA toured the facility inside and out and completed a Health and Safety check on residents in care. Residents observed in common areas, in rooms and in office. LPA explained reason for visit with Administrator.

During the investigation interviews were conducted and records reviewed.

Interviews conducted with R1 and R1's responsible party showed they were not informed that R1 was placed on hospice. R1 stated they were not diagnosed with a terminal illness and did not know they were under hospice care at the facility. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED per Title 22. See citations on the attached LIC. 9099D. CONT...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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 3
Control Number 24-AS-20210813150239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited
CCR
87468.1(a)(8)
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87468.1 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...(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Administrator stated that emails will be sent out for future diagnosis and plans of care. This will show attempts are made to contact families/responsible parties. Administrator to provide plan in writting to CCL by POC date.
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This requirement was not met as evidence by: Interveiws conducted disclosed R1 and R1's responsible party were not informed that R1 was placed on hospice. R1 was unaware they were diagnosed with a terminal illness and did not know they were under hospice care at the facility.
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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: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20210813150239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/20/2022
NARRATIVE
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Exit interview conducted and appeal rights given.

Due to COVID precautionary measures reports will be emailed to:anjaleoni@icloud.com. A delivered and read receipts serving as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3