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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203505
Report Date: 01/24/2023
Date Signed: 01/25/2023 12:26:51 PM


Document Has Been Signed on 01/25/2023 12:26 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
SIERRA CASCADE AC/SC, 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: 42DATE:
01/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Care Coordinator, Jean AbradanTIME COMPLETED:
04:35 PM
NARRATIVE
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On 1/24/23 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced for a case management on a previous visit made on 8/4/22 by LPA. LPA was met by Direct Care Staff, Ong Vang and was COVID pre-screened at time of entry.

Care Coordinator, Jean Abragan was contacted and arrived some time later. LPA discussed reason for visit and completed a tour with Care Coordinator. A health and safety check was completed on residents in care. Residents observed in common areas and in rooms at time of visit.

During previous complaint visit made on 8/4/22, LPA requested and reviewed documentation pertaining to medications for residents in care. During review of records, LPA observed notes stating R1’s physician was concerned with R1’s weight loss. LPA requested weight loss records from Administrator who was unable to provide.

LPA also reviewed Central Stored Medication Log for residents in care. LPA observed facility notes stating the physician for R1 was concerned “medications were not ordered since October” 2022. Date of this note was 2/17/22.

Based on the following, deficiencies cited per Title 22 on 809D.

Exit interview completed with Care Coordinator, Jean. A copy of this report and appeal rights were given.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/25/2023 12:26 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SIERRA VILLA REST HOME
FACILITY NUMBER: 107203505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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All staff providing care to complete training. Facility to provide traiing material and sign in sheet to CCL by POC date
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This requirement was not met as evidence by: LPA observation of residents file. During review of records, LPA observed notes stating R1’s physician was concerned with R1’s weight loss. LPA requested weight loss records from Administrator who was unable to provide. This poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
02/03/2023
Section Cited

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87465 Incidental Medical and Dental Care
(4) The licensee shall assist residents with self-administered medications as needed.
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All staff providing care to complete training. Facility to provide traiing material and sign in sheet to CCL by POC date
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This requirement was not met as evidence by: LPA observation of facility notes stating the physician for R1 was concerned “medications were not ordered since October” 2022. Date of this note was 2/17/22.
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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: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2