547201807-5-27-2022-24-AS-MYAG-CETRQ6-20220527131301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547201807
Report Date: 05/27/2022
Date Signed: 05/27/2022 01:13:33 PM

Document Has Been Signed on 05/27/2022 01:13 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SIERRA VILLAGE ASSISTED LIVING		FACILITY NUMBER:	547201807
ADMINISTRATOR:	BELINDA COULSON		FACILITY TYPE:	740
ADDRESS:	73 MOLENSTRAAT		TELEPHONE:	(559) 713-1911
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	22	CENSUS: 11	DATE:	05/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Administrator Renata Puckett		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 05/27/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Tiffany Loftin, Supervisor. Administrator Renata Puckett was called and arrived shortly and conduct tour with LPA.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

Administrator inquired fingerprinted clearance for supervisor. Administrator confirmed supervisor is not fingerprinted cleared.

Residents’ room toured and observed to be adequately furnished and lit. LPA observed 1 shared residents bed to be at least 6 feet apart and 10 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. Food supply was checked and appeared to be an adequate supply. LPA observed 30 day PPE supplies. Cleaning supplies were stored in locked storage room. LPA checked residents’ locked medications. A sample of resident records reviewed to have updated emergency contact information. Facility has mitigation plan on file.

A deficiency and an immediate Civil Penalty of $500 was assessed. See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/3/22. The following updated forms were requested: Lic 309, Lic 400, Lic 402, Lic 500, Lic 9020, and current liability insurance. LPA received copy of Lic 308, Lic 610E, and current Administrator certificate.

A copy of this report and appeal rights was provided to the Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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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Document Has Been Signed on 05/27/2022 01:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIERRA VILLAGE ASSISTED LIVING	FACILITY NUMBER: 547201807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA and Administrator observed staff that is not fingerprinted cleared working at facility. Administrator stated staff is required an exemption and paperwork was submitted but exemption is not completed. Therefore, fingerprint is not cleared which poses an immediate risk to the health and safety of the residents.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Staff person is to be removed from the facility immediately and not permitted back until fingerprinted cleared and associated. POC cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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