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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209373
Report Date: 12/18/2023
Date Signed: 12/18/2023 12:24:04 PM

Document Has Been Signed on 12/18/2023 12:24 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(415) 810-0145
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY: 22CENSUS: 20DATE:
12/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
12:24 PM
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On 12/18/23, Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA introduced self, stated the purpose of the visit and met with Administrator Kala Gibson.

The purpose of today’s visit is to address incident report and SOC 341 that the department received on 12/12/23. It was reported that on 12/10/23, staff 1 (S1) slapped and scolded R1. LPA conducted interview with Administrator, reviewed submitted photos and records which confirm S1 had slapped R1’s arm multiple times leaving bruises on R1’s arm the next day. S1 demanded R1 to go to her room and scolded R1 that grabbing S1’s hand was not okay.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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 12/18/2023 12:24 PM - It Cannot Be Edited


Created By: Mai Yang On 12/18/2023 at 12:05 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: KERN VILLAGE ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 157209373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement has not been met by:
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S1 was terminated on 12/12/23. All staff have been retrained in-service training on 12/13/23. In-Service training on elderly abuse including emotional, physical, mental, and verbal. Rooster of staff attendance and training documents was received. POC cleared.
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Based on interviews conducted, reviews of photos and records, on 12/10/23 S1 had slapped R1 on the hand multiple times leaving R1 bruises on the forearm. S1 scold and demanded the resident to go to the resident’s room which poses a potential health, safety or personal rights risk 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: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
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