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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 08/24/2022
Date Signed: 08/24/2022 02:01:20 PM

Document Has Been Signed on 08/24/2022 02:01 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PRESTIGE ASSISTED LIVING AT VISALIAFACILITY NUMBER:
547200844
ADMINISTRATOR:CRYSTAL GONZALESFACILITY TYPE:
740
ADDRESS:3120 W. CALDWELLTELEPHONE:
(559) 735-0828
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 72CENSUS: 43DATE:
08/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Administrator Crystal GonzalesTIME COMPLETED:
02:30 PM
NARRATIVE
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On 8/24/22/22, Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA introduced self, stated the purpose of the visit and met with the Administrator Crystal Gonzales

The purpose of the visit is to address incident that occurred on 06/01/22 where Staff 1 (S1) removed resident 1 (R1) lotions and after shave without resident’s permission.

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

An exit interview was conducted, and a Plan of Correction was reviewed and developed with administrator. A copy of this report and appeal rights was provided to Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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 08/24/2022 02:01 PM - It Cannot Be Edited


Created By: Mai Yang On 08/24/2022 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PRESTIGE ASSISTED LIVING AT VISALIA
FACILITY NUMBER: 547200844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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Licensee shall submit a plan of steps that will be taken to ensure the regulation is met by the due date.
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Based on records reviewed and interview conducted, on 06/01/22 Staff 1 (S1) removed resident 1 (R1) items from resident room without resident’s permission which poses/posed a potential health, safety or personal rights 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 Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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