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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201807
Report Date: 06/08/2021
Date Signed: 06/09/2021 06:45:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIERRA VILLAGE ASSISTED LIVINGFACILITY NUMBER:
547201807
ADMINISTRATOR:BELINDA COULSONFACILITY TYPE:
740
ADDRESS:73 MOLENSTRAATTELEPHONE:
(559) 713-1911
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:22CENSUS: 12DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Belinda CoulsonTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Belinda Coulson and discussed the purpose of the visit.

LPA began the tour with the Administrator Belinda Coulson at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in cabinet. LPA observed the following personal protective equipment in a storage cabinet; hand sanitizer, gowns, gloves, and masks. Staff records were reviewed for infection control training. Resident’s files have updated emergency contact information.

Facility has mitigation plan on file.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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