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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209325
Report Date: 07/15/2024
Date Signed: 07/16/2024 07:49:33 AM

Document Has Been Signed on 07/16/2024 07:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAVANNA ASSISTED LIVING LLCFACILITY NUMBER:
157209325
ADMINISTRATOR/
DIRECTOR:		FE VILLA-TUNGPALANFACILITY TYPE:
740
ADDRESS:9013 STATEN ISLAND DRTELEPHONE:
(661) 889-6948
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 4DATE:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Licensee Sarah Mazibuko and Administrator Fe Villa- TungpalanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 07/15/24, Licensing Program Analyst (LPA) M. Yang conducted case management-deficiency visit to the facility. LPA introduce self, stated the purpose of the visit, and met with Licensee Sarah Mazibuko and Administrator Fe Villa- Tungpalan.

The purpose of the visit is to address the incident report where the department was notified that the Licensee did not provide proper written eviction notice to R1.

Therefore, as a result, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. An exit interview was conducted. A copy of this report and appeal rights was provided to Licensee, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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 07/16/2024 07:49 AM - It Cannot Be Edited


Created By: Mai Yang On 07/15/2024 at 01:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAVANNA ASSISTED LIVING LLC
FACILITY NUMBER: 157209325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2024
Section Cited
CCR
87224(a)

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The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)…

This requirement is not met as evidenced by:
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Licensee will submit a written plan of how evictions shall be presented to residents and/or their responsible party to Department by POC due date.
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Based on interview and record review, the facility informed R1’s payer and family of eviction notice. Eviction notice was not valid and did not meet the eviction procedure. This poses a potential health and safety risks to persons 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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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