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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209373
Report Date: 06/11/2024
Date Signed: 06/12/2024 09:09:46 AM

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
06/03/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240603113122
FACILITY NAME:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(760) 376-1367
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY:22CENSUS: 20DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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Staff forced a resident to bathe
INVESTIGATION FINDINGS:
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On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation and deliver complaint finding on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson.

During the course of the investigation, the Department conducted interviews, received copies of records, and toured the facility. Based on interviews that were conducted, S1 forces R1 to take showers. Based on interviews conductd, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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 3
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
06/03/2024 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20240603113122

FACILITY NAME:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(760) 376-1367
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY:22CENSUS: 20DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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9
Staff are not addressing mold at the facility.
Staff do not assist residents with ambulating.

INVESTIGATION FINDINGS:
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On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a complaint initial complaint investigation and deliver complaint finding on the above allegations. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson.

During the course of the investigation, the Department conducted interviews, received copies of records, and toured the facility. All the rooms were toured with no signs of mold. Staff and residents confirm staff assists resident, transferring into wheelchair when needed and upon request. Base on interviews conducted,the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240603113122
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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87468.1(a)(1)
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To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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All staff In-Service training on resident’s personal rights is to be completed. Staff rooster of attendance of in-service training and training materials is to be submitted to Fresno CCL by POC date 06/21/24.

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Based on interviews conducted, S1 uses social force on R1 to take showers which poses a potential health and safety risk for the person in care.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3