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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:39:05 PM


Document Has Been Signed on 08/24/2022 01:39 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PRESTIGE ASSISTED LIVING AT VISALIAFACILITY NUMBER:
547200844
ADMINISTRATOR:CRYSTAL GONZALESFACILITY TYPE:
740
ADDRESS:3120 W. CALDWELLTELEPHONE:
(559) 735-0828
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:72CENSUS: 43DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Crystal GonzalesTIME COMPLETED:
01:40 PM
NARRATIVE
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On 08/24/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator Crystal Gonzales.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

At 12:00 PM, LPA and Administrator observed Clorox cleaning bottle on dining counter. Food supply was checked and appeared to be an adequate supply. At 12:12 PM, LPA and Administrator observed cleaning chemical bottles unlock under sink in activity room. Ten percent of resident’s room toured and observed to be adequately furnished and lit. Ten percent bathrooms are observed with securely fastened grab bars. Bathrooms observed trash bin with no lid. Hand washing posting not observed by bathroom sinks. LPA observed 30 days PPE supplies.

LPA checked residents’ locked medications. A sample of resident records reviewed to have updated emergency contact information. Staff records were reviewed for good health and infection control training.

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

An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. The following documents are requested and submitted to Fresno CCL by: 8/30/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9020, current Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to the Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 08/24/2022 01:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PRESTIGE ASSISTED LIVING AT VISALIA
FACILITY NUMBER: 547200844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at 12:00PM LPA and Administrator observed a Clorox Bleach Germicidal Cleaner bottle on top of counter in the dining room while 18 residents were sitting in the dining room. At 12:10 PM, LPA and Administrator observed five cleaning chemicals stored under sink in the activity room unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Administrator immediately removed the cleaning chemical bottles and locked in housekeeping storage room. POC cleared during visit
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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