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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208809
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:02:19 PM



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
11/12/2021 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20211112131114
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: 63DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Martin Vale, AdministratorTIME COMPLETED:
09:17 AM
ALLEGATION(S):
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Staff not wearing mask.
INVESTIGATION FINDINGS:
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On 12/10/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Administrator Martin Vale.

During the course of the investigation, LPA toured the facility with Administrator. During the facility tour, LPA observed S1 not wearing face covering in facility kitchen. All staff in facility observed to be wearing face covering during the tour.

Based on observation, the facility failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care in that 1 out 2 kitchen staff were observed to be not wearing facial covering in violation of official government orders requiring the wearing of face coverings while working under specified conditions. Therefore, the above allegation are found to be SUBSTANTIATED.

A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this report and Appeal rights will be provided via email. Report signed on-site.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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 4
Control Number 24-AS-20211112131114
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)(2): Residents…shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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By the due date, the Administrator will submit a plan detailing steps the facility will take to ensure S1 wear face mask while in the facility as mandated. The plan shall include S1 training on facial covering and proof shall be submitted with POC.
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Based on observation, the facility did not ensure staff are wearing facial coverings as mandated when it was observed that 1 out of 2 kitchen staff were not wearing facial coverings during the lunch period. This poses a potential health and safety risk to residents 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) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
11/12/2021 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20211112131114

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: 63DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Martin Vale, AdministratorTIME COMPLETED:
09:17 AM
ALLEGATION(S):
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9
Staff not keeping kitchen free from pests.
Staff not wearing gloves when handling food(s).
INVESTIGATION FINDINGS:
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On 12/10/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Martin Vale.

During the course of the investigation, LPA toured the memory care kitchen and observed two live roaches and several dead roaches on the floor however during staff interviews, it was reported that pest control has come to facility twice to treat the kitchen. LPA obtained contact information for Pest Control and verified that service had been done on the inside and outside of the facility on multiple occasions. Allegation is UNSUBSTANTIATED due to facility seeking assistance from pest control to eradicate the roaches, however, LPA informed Administrator that pest control service needs to continue in an effort to ensure eradication.

LPA toured the facility main kitchen and observed staff not wearing gloves when handling foods. Facility records were reviewed. Facility in-service training record provided no requirement of wearing gloves when handling food. Based on LPA records review, observations, and interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/12/2021 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20211112131114

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: 63DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Martin Vale, AdministratorTIME COMPLETED:
09:17 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not serving residents food in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
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13
On 12/10/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator Martin Vale.

During the course of the investigation, the Department conducted interviews and toured the facility. LPA interviewed staffs and observed meals being served during tour. Based on the interviews conducted and observation, it is confirmed that meals are served timely during the meal period 8am-9am, 12pm-1pm, and 5pm-6pm.

Based on interviews with staffs and observation, the allegation above is UNFOUNDED, meaning it was false, could not have happened, and/or is without reasonable basis. We have therefore dismissed the complaint.
Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4