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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208809
Report Date: 09/30/2021
Date Signed: 09/30/2021 11:12:50 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/11/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210611102316
FACILITY NAME:PARK VISALIA ASSISTED LIVINGFACILITY NUMBER:
547208809
ADMINISTRATOR:RENEE HAMILTONFACILITY TYPE:
740
ADDRESS:3939 WEST WALNUT AVENUETELEPHONE:
(559) 625-3388
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:110CENSUS: 62DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Administrator, Martin ValeTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident was assaulted by another resident.
INVESTIGATION FINDINGS:
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On 09/30/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Martin Vale.

During the course of the investigation, LPA conducted staff interviews and reviewed records.

Staff interviews and record reviews revealed that, R1 entered the dining area through the courtyard of the facility. Upon entry, R2 approached R1 and R2 began “saying something mean like” to R1. R2 then “pushed” R1. S1 observed R2 approaching R1 and attempted to intervene before the incident escalated, however, before S1 arrived to the area where R1 and R2 were standing, R2 had already “pushed” R1. S1 immediately escorted R2 to R2’s apartment while the S2 assisted R1. Facility staff initiated emergency services. An EMT arrived, assessed R1, and transported R1 to the hospital. Facility staff contacted the responsible parties for both R1 and R2.
CONTINUED TO LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20210611102316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/30/2021
NARRATIVE
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It was determined that the facility did not act negligently and the incident that occurred was not due to a lack of care or supervision.

Based on interviews conducted with staff and records review, the allegation: Resident was assaulted by another resident is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies issued during this inspection.

An exit interview was conducted with Administrator. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site by Facility Representative

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
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