547208809-9-1-2023-24-AS-SMOA-CVVLU5-20230921090322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547208809
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:56:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2023 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20230626083044

FACILITY NAME:	PARK VISALIA ASSISTED LIVING		FACILITY NUMBER:	547208809
ADMINISTRATOR:	MARTIN VALE		FACILITY TYPE:	740
ADDRESS:	3939 WEST WALNUT AVENUE		TELEPHONE:	(559) 625-3388
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	110	CENSUS: 83	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Executive Director/ Administrator Mandy Rancour		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Licensee does not ensure there is an Administrator or designated substitute present at all times
Staff failed to administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit and reviewed records. LPA met with Administrator Mandy Rancour and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observations, interviews and record review a designated substitute was not present at all times while Administrator was on leave. LPA reviewed Residents (R1) medication records and observed medication that was logged in the Centrally stored medication and destruction record (CSMDR) was not sufficient to meet the administration of medication as directed by the physician.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230626083044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PARK VISALIA ASSISTED LIVING	FACILITY NUMBER: 547208809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/16/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	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). Administrator to conduct medication audits routinely and ensure medication is refilled in a timely manner.
	8 9 10 11 12 13 14	Medication that was logged in the Centrally stored medication and destruction record (CSMDR) was not sufficient to meet the administration of medication as directed by the physician. LPA observed CSMDR to be incomplete or missing data.	8 9 10 11 12 13 14
Type B 09/15/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Citation was cleared prior to visit with change of Administrator
	8 9 10 11 12 13 14	A qualified substitute was not designated and present at all times while Administrator was on leave.	8 9 10 11 12 13 14

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: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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