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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208809
Report Date: 08/19/2021
Date Signed: 09/24/2021 10:08:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 61DATE:
08/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Business Office Director, Shannon SeeTIME COMPLETED:
10:45 AM
NARRATIVE
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This is an amended report.

On 08/19/2021, Licensing Program Analysts (LPAs) Walton and Yang arrived unannounced to conduct a Case Management visit. LPAs introduced selves, stated the purpose of the visit, and requested to meet with the Administrator. Administrator, Martin Vale is not available during this inspection. LPAs met with Business Office Director (BOD), Shannon See.

The purpose of this visit is to follow up on an Incident Report that was submitted to the Fresno CCL office on 08/09/2021. It was reported that on 07/23/2021, a Noc-shift medication technician (Med-Tech) found multiple medications in R1's room. The Med-Tech reported that R1 was "not R1's self" and was "more confused" than usual. Med-Tech contacted 911 and R1 was transported to the hospital. Medications were removed and placed in a locked room inaccessible to residents in care.

Upon further review of this incident, it was determined that resident obtained the medication while on an outing and brought it back to facility unbeknownst to facility staff. Facility informed resident’s responsible party that all medications have to be secured for resident’s safety.

Also discussed were multiple incident reports received from facility that were not submitted within seven days of the incident’s occurrence. Deficiency regarding reporting requirements is being cited in accordance to California Code of Regulations, Title 22, on the attached 809D.

An exit interview conducted with (BOD). A plan of correction was developed and reviewed with BOD. Due to COVID-19 pre-cautionary measures, a copy of this report and appeal rights will be provided via email and an electronic read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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Citations on this Visit Report are Under Appeal!

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARK VISALIA ASSISTED LIVING
FACILITY NUMBER: 547208809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/25/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report...to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This requirement was not met as evidenced by:
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Based on record reviews, Licensee submitted late incident reports on the following dates: 7/23/21, 7/27/21 and 8/1/21. This poses a potential health and safety risk to persons in care.
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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2