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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 07:15:18 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
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:
04:49 PM
MET WITH:Administrator, Sundari Susan KendakurTIME COMPLETED:
05:06 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's assistive device hit resident resulting in broken teeth.
Resident's responsible party was not informed of an incident involving resident getting injured.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Adminsitrator.

During investigation interviews conducted and records reviewed. Special incident reports from the facility did not show that R1 was injured at any time during their residence at the facility. R1 was found to have a chip in the tooth during interviews. Staff interviews disclosed that the facility was unaware of any incident resulting in broken teeth. Althought the above allegations may or may not have occurred the preponderance of evidence does not meet the standard, therefore the above allegation is found to be UNSUBSTANTIATED per Title 22. No deficiencies cited. Exit interview conducted. Due to COVID precautionary measures reports will be emailed to: anjaleoni@icloud.com. A delivered and read receipts serving as confirmation.
Unsubstantiated
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)
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