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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208809
Report Date: 02/13/2024
Date Signed: 02/13/2024 01:45:40 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
11/03/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20231103113620
FACILITY NAME:PARK VISALIA ASSISTED LIVINGFACILITY NUMBER:
547208809
ADMINISTRATOR:AMANDA KELSEYFACILITY TYPE:
740
ADDRESS:3939 WEST WALNUT AVENUETELEPHONE:
(559) 625-3388
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:110CENSUS: 77DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Executive Director/ Administrator Amanda Kelsey TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not following resident's care plan
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 Amanda Kelsey 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 the Staff did not have sufficient training to provide and follow residents care plan.

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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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-20231103113620
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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision…

This requirement was not met as evidenced by:
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Administrator to provide in service training to staff to ensure staff are following care plan for residents transferring needs and provide proof of training to CCLD by due date. Administrator to ensure proper training is provided to staff before working with residents in care.
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Based on interviews and record review; facility staff are not following residents care plan for 2-person assist when transferring/ assisting resident with toileting needs.
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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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
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