547200844-9-5-2023-24-AS-KKAR-CVE368-20230905175754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 09/05/2023
Date Signed: 09/05/2023 05:59:15 PM

Document Has Been Signed on 09/05/2023 05:59 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:	CRYSTAL GONZALES		FACILITY TYPE:	740
ADDRESS:	3120 W. CALDWELL		TELEPHONE:	(559) 735-0828
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	72	CENSUS: 39	DATE:	09/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Trina Sinfit		TIME COMPLETED:	06:15 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 9/5/2023, 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 Trina Sinift LPAs conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstruction. LPAs toured locked office storage rooms, and laundry rooms. LPAs observed facility common areas which were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed non-perishable and perishable foods. At 11:39 AM LPA observed the Ice Machine to have brown buildup underneath the door lift area. LPAs toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Fire extinguishers observed throughout the facility with service date of July 13, 2023. Bathrooms were properly equipped with non-slip mats and grab bars. Hot water temperature was tested between 105 degrees F and 120 degrees in several resident bathrooms. Carbon monoxide detector tested and operational in two hallways. Memory care toured with dining area/ Kitchen; several rooms toured. Residents observed with several care givers in commons areas playing music and exercising. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. 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: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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 09/05/2023 05:59 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: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(29)

General Food Service Requirements

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 Ice Machine to have brown buildup underneath the door lift area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Administrator to have staff unplug, defrost and deep clean ice machine and complete routine cleaning to prevent future issues.

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. 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 2 out of 4 person medication audit revealed for Resident 1 (R1) 2 dosages missed with no notes on MARS and Resident 2 (R2) one pill was missing which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Administrator to submit a statement of intent to provide training to all staff in regard to correct documentation of Centrally stored medication and destruction record (CSMDR) and MARs. Administrator to conduct medication audit to ensure medications are given as prescribed

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: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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: 09/05/2023

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 8/25/2023. At 4:23 PM LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR) and observed medication audit revealed for Resident 1 (R1) 2 dosages missed with no notes on MARS and Resident 2 (R2) one pill was missing. LPA also observed the CSMDR to be incomplete.

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 9/19/2023: 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: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC809 (FAS) - (06/04)

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