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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208958
Report Date: 08/24/2023
Date Signed: 08/24/2023 05:46:56 PM


Document Has Been Signed on 08/24/2023 05:46 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:VISALIA SENIOR LIVING CAREFACILITY NUMBER:
547208958
ADMINISTRATOR:RAMOS, ANGELAFACILITY TYPE:
740
ADDRESS:310 EAST ROBIN AVETELEPHONE:
(559) 747-2182
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:6CENSUS: 5DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Angela Ramos, Licensee/AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 8/24/23 at 3:43 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Angela Ramos arrived a short time later.

LPA toured inside and outside the facility. No obstructions observed. Facility set at comfortable temperature. Smoke and carbon monoxide combo detector tested and operational. Fire extinguishers last serviced on 1/24/23. Hot water in hall bathroom measured at 116.4 degrees F. Bedrooms observed with sufficient lighting and furniture. Non-skids mats and grab bars observed in both bathrooms.

The following deficiencies were observed:
1. One spray bottle of cleaner observed accessible on top of dryer in accessible laundry room; and cabinet where a bottle of bleach and other cleaning solutions are kept was observed with a small lock that was not secured or working.
2. Cockroach nymph was observed in master bathroom shower.
3. LPA observed non-perishable food supply did not meet minimum of one week.

Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds.

Due to time constraints, LPA will return at a later date to continue the Annual inspection and complete the Inspection Tool. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, whose signature on this form confirms receipt of these documents.
***The following updated forms are to be submitted to CCL within two weeks: LIC308, LIC500, LIC610E, LIC9020, proof of liability insurance***
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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 08/24/2023 05:46 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VISALIA SENIOR LIVING CARE
FACILITY NUMBER: 547208958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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. One spray bottle of cleaner observed accessible on top of dryer in accessible laundry room; and cabinet where a bottle of bleach and other cleaning solutions are kept was observed with a small lock that was not secured or working, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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During the inspection, Licensee immediately placed spray bottle of cleaner into the cabinet where bleach/cleaners are stored and replaced the lock to a working lock. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2023 05:46 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VISALIA SENIOR LIVING CARE
FACILITY NUMBER: 547208958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. Cockroach nymph was observed in master bathroom shower, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee will submit proof of written plan to address how the facility will mitigate potential roach infestation, to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/24/2023 05:46 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: VISALIA SENIOR LIVING CARE
FACILITY NUMBER: 547208958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
87555(b)
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.


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. LPA observed non-perishable food supply did not meet minimum of one week, which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will submit proof of purchase of nonperishable foods to meet the minimum 7-day requirement, to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4