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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209373
Report Date: 06/11/2024
Date Signed: 06/12/2024 09:11:00 AM

Document Has Been Signed on 06/12/2024 09:11 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:KERN VILLAGE ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
157209373
ADMINISTRATOR/
DIRECTOR:		GIBSON, KALAFACILITY TYPE:
740
ADDRESS:32 BURLANDO ROADTELEPHONE:
(760) 376-1367
CITY:KERNVILLESTATE: CAZIP CODE:
93238
CAPACITY: 22CENSUS: 20DATE:
06/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Kala Gibson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 06/11/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Administrator Kala Gibson. LPA conducted case management-deficiency visit with Administrator.

During the course of the investigation, LPA toured the facility with Administrator. LPA observed bathroom door missing in shared bedroom.

A Deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit interview conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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 06/12/2024 09:11 AM - It Cannot Be Edited


Created By: Mai Yang On 06/11/2024 at 01:10 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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Licensee shall ensure the facility is in good repaired at all times. Licensee shall ensure that there is a door to the bathroom in Room 7 by POC due date. Proof shall be submitted to the department by the POC due date of 06/14/24.

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Based on observation and interviews conducted, at 12:01PM, Room 7 a shared room, was missing a bathroom door and has not been replace for a while which poses a potential health and safety risk for 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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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