Inspection Report
Re-Inspection
Census: 53
Deficiencies: 6
Nov 20, 2025
Visit Reason
This is an onsite revisit survey conducted from 11/19/25 through 11/20/25 to verify correction of previous deficiencies cited on 6/5/25 at Sierra Hills Assisted Living Community.
Findings
The facility failed to meet several state rules and regulations related to infection control, immunization policies, food safety, quality improvement, and licensure survey posting. Deficiencies included failure to ensure tuberculosis testing for employees and residents, inadequate food temperature monitoring, and lack of a self-assessment survey for quality improvement. The census was 53 during the inspection.
Deficiencies (6)
| Description |
|---|
| Failed to ensure 3 of 5 sample employees were tested or screened for tuberculosis (TB) as appropriate on an annual basis. |
| Failed to implement influenza and pneumococcal immunization policy for 5 of 7 sample residents and failed to ensure residents were tested for tuberculosis prior to admission for 4 of 7 sample residents. |
| Failed to ensure food was prepared, stored, and distributed under sanitary conditions in 1 of 1 kitchen, related to temperature monitoring of food storage units. |
| Failed to maintain sanitary environment of the kitchen, including ice machine maintenance and dishwasher sanitization logs. |
| Failed to have an active quality improvement program including annual self-assessment survey and satisfaction survey. |
| Failed to post the state licensure survey results in a manner conducive for public view. |
Report Facts
Census: 53
Temperature documentation days missing: 13
Temperature documentation days missing: 16
Employees tested for TB: 3
Residents reviewed for immunization: 7
Residents not tested for TB prior to admission: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David J. Lovato | Executive Director (Interim) | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 20, 2025
Visit Reason
A complaint survey was conducted by Healthcare Licensing and Surveys from 11/19/25 through 11/20/25, prompted by complaint intake LIC-26-011.
Findings
The facility failed to implement their policy and procedure for ensuring the investigation following an allegation of abuse, neglect, or incidents affecting resident health, welfare, or safety was reported to the Licensing Division in a timely manner for 6 of 6 incidents reviewed.
Complaint Details
The complaint investigation found that for 6 incidents reviewed, the facility did not report the incidents to the state survey agency as required. Specific incidents involving residents #1 through #5 were reviewed with dates ranging from 7/27/24 to 9/20/25. The clinical service director interview confirmed responsibility for completing investigations and submitting results to the state agency.
Deficiencies (1)
| Description |
|---|
| Failure to report incidents affecting the health, welfare, or safety of residents to the Licensing Division in a timely manner as required by policy and state regulations. |
Report Facts
Incidents reviewed: 6
Incident dates: Jul 27, 2024
Incident dates: Sep 20, 2025
Completion date for corrective measures: Jan 20, 2026
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dino J. Lovato | Interim Executive Director | Signed plan of correction and corrective action acceptance |
| Jean Yenni | Signed acceptance of plan of correction |
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