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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:53:48 PM


Document Has Been Signed on 03/21/2022 02:53 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:PARK VISALIA ASSISTED LIVINGFACILITY NUMBER:
547208809
ADMINISTRATOR:MARTIN VALEFACILITY TYPE:
740
ADDRESS:3939 WEST WALNUT AVENUETELEPHONE:
(559) 625-3388
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:110CENSUS: 61DATE:
03/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Martin Vale, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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On 03/21/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivery an amended complaint investigation and met with Martin Vale, Administrator. LPA interviewed staffs and resident.

During the course of an investigation, a deficiency was observed relation to personal rights of resident in care. Specifically, S1 yelled at R1 while caring for R1.

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

Exit interview conducted. Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/21/2022 02:53 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: PARK VISALIA ASSISTED LIVING
FACILITY NUMBER: 547208809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2022
Section Cited

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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met:
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On 1/13/22, S1 yelled at R1 while caring for R1 which poses an immediate health and safety and personal rights risk to the person in care.
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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) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2