547200844-7-16-2024-24-AS-KKAR-D78UZX-20240716160214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:02:46 PM

Document Has Been Signed on 07/16/2024 04:02 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:	PRESTIGE ASSISTED LIVING AT VISALIA		FACILITY NUMBER:	547200844
ADMINISTRATOR:	SINIFT, KATRINA		FACILITY TYPE:	740
ADDRESS:	3120 W. CALDWELL		TELEPHONE:	(559) 735-0828
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	72	CENSUS: 31	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Katrina Sinift		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/16/2024, Licensing Program Analysts (LPAs) K. Kaur and K. Brown arrived unannounced at the above facility to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit and met with Executive Director Katrina Sinift LPA conducted facility tour with Administrator. LPAs observed required posting. All pathways, entrances and exits were clear from obstruction. LPA toured locked office storage rooms, and laundry rooms. LPA observed facility common areas which were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. At 10:34 AM LPA observed cleaning solution in cabinet in the dining area. The kitchen was observed clean, in good repair with necessary items and appliances. At 10:46 AM LPA did not observe 7-day supply of nonperishable food. 2-Day perishable foods observed. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. At 11:44 AM LPA observed in Room 221 Block of knifes on kitchen counter and Chemicals and cleaning supplies under kitchen sink. Fire extinguishers observed throughout the facility with service date of July 8, 2024. Bathrooms were properly equipped with non-slip mats and grab bars. Carbon monoxide detector tested and operational in two hallways. Memory care toured with dining area/ Kitchen; several rooms toured. Residents observed with several caregivers in commons areas assembling puzzles. At 11:19 AM LPA conducted a medication audit of memory care resident and did not observe residents’ response to PRN medication. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured main outside Patio from dinning room which was observed with seating and shade. At 12:28 PM LPA observed unlocked gardening tools. Cleaning supplies and chemicals are kept locked maintenance room. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified. Continued to next page...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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 07/16/2024 04:02 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRESTIGE ASSISTED LIVING AT VISALIA	FACILITY NUMBER: 547200844
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 3 out of 6 residents rooms were observed with sharps, chemicals which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Items were removed or locked during inspection. Administrator to visit all resident rooms to ensure no sharps or chemicals are kept in rooms. Administrator to submit a report of findings to LPA when completed.

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 nonperishable foods did not meet 7 day requirements which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator to re-stock non-perishable food to meet requirements and submit pictures, receipts of purchase by due date.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/16/2024 04:02 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRESTIGE ASSISTED LIVING AT VISALIA	FACILITY NUMBER: 547200844
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 residentsr response was not documented to PRN medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator to submit a statement of intent for implementation of new process to complete the required documentation of PRN medication and complete an in service training of change of processes.

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents records reviewed, which poses an immediate health, safety or personal rights risk to persons in care. R1's physicians report does not contain accurate diagnoses of Diabetes, medication management regarding insulin and glucose testing. R2’s Physicians report missing ambulatory status.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	AD has agreed to obtain an updated physician’s report for R1. Additionally, an audit will be conducted of all physicians reports to ensure current/accurate information. Written statement of audit will be submitted for documentation of correction. All resident identified as needing updated Physicians report will obtain a current report.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PRESTIGE ASSISTED LIVING AT VISALIA	FACILITY NUMBER: 547200844
	VISIT DATE: 07/16/2024

NARRATIVE

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Facility files were reviewed for Resident council Meeting record, plan of operation with dementia care policy. Last fire drill conducted on 5/29/2024. Annual Fire Alarm inspection & Testing completed on 2/28/2024. LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR)

Deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/23/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with
appeal rights were provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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