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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209373
Report Date: 08/02/2024
Date Signed: 08/02/2024 02:43:42 PM

Substantiated


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
12/14/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231214090626
FACILITY NAME:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(415) 810-0145
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY:22CENSUS: DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Anthony Barbato and Licensee Legal Representative Iustina MigneaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left a resident soiled while in care
Staff are not providing adequate care and supervision to a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, Licensing Program Analyst (LPA) M. Yang delivered findings for the above allegations. LPA met with Licensee Representative Anthony Barbato.

The Department conducted interviews, reviewed records, and toured the facility. Based on the interviews conducted, records reviewed, and observations made by the LPA on the 12/18/2023 facility visit, the above allegations are Substantiated. R1 was observed soiled while in care. Facility staff did not ensure R2 received his medications to treat his insulin-dependent diabetes condition and did not monitor the resident’s glucose level, which resulted in the resident’s hospitalization and death. Citations were issued on complaint #24-AS-20231228152212 for care and supervision and appeal rights were provided.

Exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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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