107203505-1-25-2023-24-AS-SMOA-CNGMDA-20230127083048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203505
Report Date: 01/24/2023
Date Signed: 01/25/2023 11:19:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
07/27/2022 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20220727142658

FACILITY NAME:	SIERRA VILLA REST HOME		FACILITY NUMBER:	107203505
ADMINISTRATOR:	SUNDARI SUSAN KENDAKUR		FACILITY TYPE:	740
ADDRESS:	175 W. SIERRA AVE.		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	49	CENSUS: 42	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Care Coordinator, Jean Abragan		TIME COMPLETED:	03:19 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not providing resident medication as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 1/24/23 Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced to deliver complaint findings for the allegation listed above. LPA was met by Direct Care Staff, Ong Vang and was 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 investigation LPA requested and reviewed documentation (physicians reports, needs and assessments, resident appraisal, VA medications prescribed, central stored medication log, resident notes including weight records, medication list, admission agreement and completed interviews).

CONT...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 24-AS-20220727142658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CONT...

Medication records and staff interviews indicated R1 was taking “Ensure”. Records provided by RP and facility could not verify there was a prescription given. RP stated medication was supposed to be provided once one day and twice the following. Facility records showed R1 was to be provided 1 can twice daily.

Although the allegation may or may not have occurred the preponderance of evidence standard per Title 22 has not been met. This allegation is UNSUBSTANTIATED.

Exit interview completed with Jean. A copy of this report was given.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 2