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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209373
Report Date: 07/17/2024
Date Signed: 07/17/2024 01:50:21 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
07/15/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240715113659
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: 22DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ashley Bell, Administrator Assistant TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff does not ensure first aid is provided for minor incidents that don't require medical treatment
INVESTIGATION FINDINGS:
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On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA and to Administrator via telephone.

During the course of the investigation, the department conduct interviews. Interviews conducted confirmed, S1 refuse to assist resident with first aid. Based on interviews conducted, 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 8 is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator Assistant, whose signature confirms received of this report.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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-20240715113659
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: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2024
Section Cited
CCR
87465(j)
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In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed…

This requirement was not met:
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Licensee shall submit steps and documents of how the facility will assist the resident with first aid to Fresno CCL office by POC due date 07/22/24.

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Based on interviews conducted, it was confirmed, S1 refuse to assist resident with first aid which poses a potential health and safety and personal rights risk to 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: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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
07/15/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240715113659

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: 22DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ashley Bell, Administrator Assistant TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure transportation needs of resident are being met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA and to Administrator via telephone.

During the course of the investigation, the Department conducted interviews and reviewed record. Interviews were conducted with resident that confirmed transportation was provided to the resident when needed to medical appointments. Therefore, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the Administrator Assistant, whose signature confirms received of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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