547208809-10-24-2023-24-AS-KKAR-CWWUXM-20231024155833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:58:43 PM

Document Has Been Signed on 10/24/2023 03:58 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 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: 76	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Executive Director, Amanda Kelsey		TIME COMPLETED:	04:00 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 10/24/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Executive Director, Amanda Kelsey. LPA toured Front Lounge/seating area and Theater while waiting for Administrator. LPA conducted the rest of the facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. The tour continued to the facility dinning and kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Ice Machine was clean and serviced on 8/2023. At 12:02 PM LPA observed unlocked chemicals in the resident laundry room. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip tile and grab bars. Hot water temperature was tested between 112.5 degrees F and 120 degrees F in several resident bathrooms. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. Memory care toured; delayed egress doors observed. At 1:25 PM LPA observed an odor in Memory Care room 120. LPA questioned Memory Care Director who informed LPA resident was recently changed after a bowel movement. LPA removed resident’s comforter and observed brown stains on the inside of the comforter. Doors and passageways are unobstructed throughout the facility and to the outside. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. 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. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. 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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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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
	VISIT DATE: 10/24/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 10/31/2023: 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.

Due to time constraints, LPA will return at a later date for an annual continuation. An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/24/2023 03:58 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 Disinfectants, cleaning solutions observed in the resident laundry room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Staff removed items immediately. Administrator will ensure in service training is provided to staff to avoid future issues.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/24/2023 03:58 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(C)

Personal Accommodations and Services

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. 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 comforter observed to be soiled which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Memory Care Executive Director removed bedding for washing and will ensure staff change at least once per week or more often when indicated to ensure that clean linen is provided to resident.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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