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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:37:48 PM


Document Has Been Signed on 08/20/2024 01:37 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:AMANDA KELSEYFACILITY TYPE:
740
ADDRESS:3939 WEST WALNUT AVENUETELEPHONE:
(559) 625-3388
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:110CENSUS: 69DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Executive Director, Amanda KelseyTIME COMPLETED:
02:00 PM
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On 08/20/24, Licensing Program Analysts (LPAs) K. Kaur and J. Leffall conducted an unannounced case management visit to the facility. The purpose of the case management visit is to follow up on Special Incident Report (SIR) submitted to CCL Office. LPA met Executive Director, Amanda Kelsey.

Facility reported on 06/10/24, Resident # 1 went AWOL and police located resident and returned to the facility. LPAs gathered documents and conducted interviews. The information provided will be reviewed; a follow up case management will be conducted if necessary.



Exit interview was conducted. A copy of this report was provided to Administrator via email, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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