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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:07:41 PM


Document Has Been Signed on 07/30/2024 03:07 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 VISALIAFACILITY NUMBER:
547200844
ADMINISTRATOR:SINIFT, KATRINAFACILITY TYPE:
740
ADDRESS:3120 W. CALDWELLTELEPHONE:
(559) 735-0828
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:72CENSUS: 32DATE:
07/30/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Administrator Katrina Sinift and Regional Director Gary AllingerTIME COMPLETED:
02:45 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) K. Kaur, Licensing Program Manager (LPM) S. Moua, and Regional Manager (RM) B. White met with Katrina Sinift, Administrator and Gary Allinger Regional Director.

Based on interviews conducted with Administrator Katrina Sinift during NCC meeting, a medication error occurred a week before Friday. Per Administrator residents had missed medication/ missed dosage from a staff that was new med-tech. Staff has been removed from medications until either further training

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



An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 03:07 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: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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POC – Discussed during the NCC.
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Based on the interviews conducted Staff missed medicaiton or missed dosage for residents.
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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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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