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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209373
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:33:18 PM

Document Has Been Signed on 07/30/2024 12:33 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:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR/
DIRECTOR:		GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(760) 376-1367
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY: 22CENSUS: 22DATE:
07/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Ashley Bell, Administrator AssistantTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 07/30/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a case management visit based on record review of incident report submitted. LPA met with Staff Destiny Wood. Staff telephone called to Administrator Kala Gibson who stated unable to attend meeting. Administrator Assistant Ashley Bell arrived later during visit.

The purpose of the visit is to address incident that occurred where S1 sold narcotic to R1.

LPA reviewed records and conducted interviews with staff and resident.



The information provide will be reviewed; a follow up case management will be conducted if necessary.

Exit Interview conducted. A copy of this report was provided to the Administrator Assistant, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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