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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209373
Report Date: 06/11/2024
Date Signed: 07/08/2024 11:04:54 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
03/07/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240307144719
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:
12:51 PM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
01:08 PM
ALLEGATION(S):
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Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings 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, residents’ medications were audit and MARs were reviewed, medications audit showed staff did not administered R1 and R2 medications as directed by physician.

Based on observation, the preponderance of evidence standard has been met, therefore, the above
allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6
are being cited on the attached LIC 9099D. 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
Control Number 24-AS-20240307144719
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 A
06/12/2024
Section Cited
CCR
87465(c)(2)
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Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include auditing the MARS and medications to Fresno CCL office by POC due date 06/12/24.
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Based on records review and observation, R1 and R2 medications were not administered by staff as instructed by physician which poses an immediate health and safety risk for the person in care.

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Licensee shall have all staff retrained Health-Related Services regulations 87465. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 06/21/24.
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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: 2 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
03/07/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240307144719

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:
12:51 PM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
01:08 PM
ALLEGATION(S):
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Unqualified staff providing care for residents
Staff are mismanaging residents records
Staff are not meeting residents hygiene needs
Staff did not prevent showers from being in disrepair
Staff did not prevent residents rooms from having mold smell
Staff are not providing adequate food service to residents
Administrator is not at the facility a sufficient number of hours
INVESTIGATION FINDINGS:
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On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings 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 with staffs and residents, toured the facility, and reviewed records. Medications technicians have all the required trainings on file. Residents’ records are stored and locked in the facility office. The resident’s bathroom shower was observed being renovated as a plan of correction for prior complaint. Arrangement for resident showering was provided to the resident. All rooms toured and were free of odor. Adequate non-perishable and perishable food were observed. Administrator is present at the facility for sufficient number of hours and available outside of operating hours.

Based on LPA record reviewed, observation, interviews which were 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: 3 of 3