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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:36:11 PM


Document Has Been Signed on 09/23/2022 12:36 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: 72DATE:
09/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Martin Vale, AdministratorTIME COMPLETED:
12:37 PM
NARRATIVE
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On 09/23/22, Licensing Program Analyst (LPA) M. Yang conducted case management-deficiency visit to the facility. LPA met with Administrator Martin Vale and stated the purpose of the visit.

The purpose of the visit is to address incident that occurred where R1 went AWOL on 09/15/22.

Therefore, as mentioned, R1 went AWOL from facility. As a result, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

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

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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 09/23/2022 12:36 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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2022
Section Cited

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a)In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.

This requirement is not met as evidenced by:
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Based on interview and record review, staff did not provided care and supervision when R1 left the facility unsupervised on 09/15/22 at approximately 09:00PM and was located approximately two blocks down from the facility by a pedestrian which poses an immediate health and safety risks to persons in care.
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Licensee has agreed to submit AWOL in-service training and rooster of staff attendance 09/26/22 to the Department.

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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: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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