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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 08/02/2024
Date Signed: 08/02/2024 06:59:56 PM

Document Has Been Signed on 08/02/2024 06:59 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/
DIRECTOR:		AMANDA KELSEYFACILITY TYPE:
740
ADDRESS:3939 WEST WALNUT AVENUETELEPHONE:
(559) 625-3388
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 110TOTAL ENROLLED CHILDREN: 0CENSUS: 71DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Executive Director, Amanda KelseyTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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On 8/2/2024, 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 area 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. 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. At 12:43 PM LPA observed 2 out of 8 rooms had knives. 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. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. Memory care toured; delayed egress doors observed. 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 one staff on duty who are CPR certified. LPA conducted a sample medication audit and observed Resident (R1) had one extra pill in bubble pack that was not given.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/9/2024: 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.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided. Immediate Civil penalties were assessed due to repeat violations.
See MouaTELEPHONE: (559) -58-4596
Kamaldeep KaurTELEPHONE: 559-243-8080
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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Document Has Been Signed on 08/02/2024 06:59 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: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 8 resident rooms had sharps (knives) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2024
Plan of Correction
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Administrator will submit statement of intent to conduct a sweep of the facility and remove any sharps that could pose a danger if readily available to residents and submit a report of findings to CCLD when completed.
Deficiency Dismissed
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 4 residents medication audit revealed an extra pill in the bubble pack that was not given to resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2024
Plan of Correction
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Licensee to submit state of intent by due date to conduct an in-service training for medication and submit records when completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See MouaTELEPHONE: (559) -58-4596
Kamaldeep KaurTELEPHONE: 559-243-8080

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024

LIC809 (FAS) - (06/04)
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