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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 05/27/2022
Date Signed: 06/07/2022 09:06:24 AM


Document Has Been Signed on 06/07/2022 09:06 AM - It Cannot Be Edited

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:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:175 W. SIERRA AVE.TELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:49CENSUS: DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrator, Sundari "Susan" KendakurTIME COMPLETED:
02:15 PM
NARRATIVE
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On 05/27/2022, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by Direct Care Staff, Venus Maliwat. Administrator was contacted and arrived a some time later. LPA had temperature taken and allowed entry into facility. LPA did not observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in hallways, common area and in rooms.

Mitigation plan was received and reviewed. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs for hand washing observed. Posting for coughing etiquette and physical distancing were not observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed in 8 of 10 rooms toured. LPA did not observed a 30 day supply of PPE but facility has available at near by location. Resident medications observed with 30 day supply. Sinks are well stocked and liquid soap for hand washing. Paper towels for hand drying were not observed due to residents having behaviors.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be not in compliance. Deficiencies cited on LIC 809D per Title 22 regulations given for COVID precautionary measures not in place.

Exit interview completed. A copy of this report and appeal rights given.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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Document Has Been Signed on 06/07/2022 09:06 AM - 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
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: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(9)
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements.

Deficient Practice Statement
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LPA observations. LPA was not screened or offered hand sanitizer at time of entry. LPA did not observe sneezing/coughing etiquette posting throughout the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Per Licensee signage will be laminated and put up by POC date. Licensee to provide picture to CCL once completed. Licensee to provide staff with personal hand sanitizers and screening questions to ensure staff will be completing tasks. Licensee to provide training to all staff on infection control regulations and new practice being put in place. Licensee to provide training material and sign in sheet to CCL by POC date.
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: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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