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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209373
Report Date: 08/02/2024
Date Signed: 08/02/2024 02:54:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231228152212
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: DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Anthony Barbato, Licensee Legal Representative Iustina Mignea, and Kala GibsonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Staff did not monitor resident's glucose level resulting in death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted interviews, reviewed records, and toured the facility. Based on the interviews conducted and records reviewed, the above allegation is Substantiated. Facility staff did not ensure R2 received his medications to treat his insulin-dependent diabetes condition and did not monitor the resident’s glucose level, which resulted in the resident’s hospitalization and death. Citation for care and supervision are issued on the attached 9099-D.

The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.

Exit Interview was conducted and Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20231228152212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 SENIORS
FACILITY NUMBER: 157209373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Personnel Requirements - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This was not met as evidenced by:

1
2
3
4
5
6
7
POC addressed during NCC.
8
9
10
11
12
13
14
Based on the interviews conducted and records reviewed, facility staff did not monitor R2’s glucose level. The facility staff also did not ensure R2 received his medications to treat his insulin-dependent diabetes condition. This resulted in R2’s hospitalization and death, which poses an immediate Health and Safety concern.
8
9
10
11
12
13
14
Type A
08/03/2024
Section Cited
CCR
87405(d)(2)
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2
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5
6
7
Administrator - Qualifications and Duties - Knowledge of and ability to conform to the applicable laws, rules and regulations.

This was not met as evidenced by:
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5
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7
POC addressed during NCC.
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9
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14
Based on interviews conducted, Administrator did not ensure resident’s care needs were met, which poses an immediate Health and Safety concern.
8
9
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14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20231228152212

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: DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Anthony Barbato and Licensee Legal Representative Iustina MigneaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek timely emergency medical services for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted interviews and reviewed records. Based on the interviews that were conducted and records reviewed, staff contacted emergency services when R2 was observed having difficulties breathing. Emergency services arrived and R2 was transported to the hospital. The allegation is Unsubstantiated. Exit interview was conducted.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20231228152212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 SENIORS
FACILITY NUMBER: 157209373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
87464(f)(4)
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2
3
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5
6
7
Basic Service - Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications…

This requirement was not met as evidenced by:
1
2
3
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5
6
7
POC discussed during NCC.
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, facility staff left resident soiled and failed to ensure resident received medications, which poses an immediate health and safety concern.
8
9
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14
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2
3
4
5
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7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4