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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:48:20 PM


Document Has Been Signed on 10/26/2023 04:48 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: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: 77DATE:
10/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Amanda KelseyTIME COMPLETED:
04:00 PM
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On 10/26/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a case management inspection regarding incident report that was received in the CCL office. Incident Report occurred on 7/30/2023 regarding medication errors. LPA explained the reason for inspection and met with Executive Director/ Administrator, Amanda Kelsey

LPA conducted a medication audit and reviewed R1’s records and observed residents PRN medication was not documented when given.

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

An exit interview was conducted with the Administrator. Report signed on-site and printed copy provided with
appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 10/26/2023 04:48 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: PARK VISALIA ASSISTED LIVING
FACILITY NUMBER: 547208809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/27/2023
Section Cited
CCR
87465(b)(3)

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87465 Incidental Medical and Dental Care (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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Licnesee to ensure a record of each PRN dose is maintained in the resident's record.
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Review of residents medication and MARs revealed PRN medication was given without proper documentation.
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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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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