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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200844
Report Date: 10/25/2025
Date Signed: 11/03/2025 03:00:50 PM

Document Has Been Signed on 11/03/2025 03:00 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:MARBELLA VISALIAFACILITY NUMBER:
547200844
ADMINISTRATOR/
DIRECTOR:		RANCOUR, MANDYFACILITY TYPE:
740
ADDRESS:3120 W. CALDWELLTELEPHONE:
(559) 735-0828
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 72CENSUS: 48DATE:
10/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Resident Care Coordinator, Brittany Polman TIME VISIT/
INSPECTION COMPLETED:
04:08 PM
NARRATIVE
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On 10/25/2025 Licensing Program Analyst (LPA) M. Garza completed a case management visit. LPA met with Medical Technician, Kimberly Reyes explained reason for visit and was permitted entry into the facility. Resident Care Coordinator, Brittany Polman arrived some time later and stated the Executive Director, Mandy Rancour was unavailable. LPA completed a health and safety check on residents in care and toured the facility. Residents were observed in common areas and in rooms.

This case management visit is being conducted for deficiencies observed during complaint visits conducted for complaint #24-AS-20250605163501 on 6/10/25 and 10/25/25. The following issues were observed: gate with lock to kitchenette preventing access to food/drink and posing a tripping hazard observed in memory care. Required postings are not posted in the facility. The complaint poster for RCFE facilities (PUB 475) was not posted. Incident reports reviewed disclosed R3 had an allergic reaction on 5/14/25 and R1 had medication in their room unlocked and accessible on 5/15/25 both posing hazards to residents in care. Deficiencies cited per California Code of Regulations, Title 22. If not corrected, deficiencies cited will pose a direct impact to residents in care.

Exit interview completed with Resident Care Coordinator, Brittany Polman. A plan of correction was developed by Brittany and reviewed by LPA. A copy of this report, deficiencies and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/03/2025 03:00 PM - It Cannot Be Edited


Created By: Mary Garza On 10/25/2025 at 03:13 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: MARBELLA VISALIA
FACILITY NUMBER: 547200844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87468(c)

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87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.
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RCD stated they will have posting placed up in the facility. RCD stated they will take pictures showing the posting were placed as proof of correction.
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This requirement was not met as evidence by LPA observation. The licensee did not comply with the section cited above in that required postings are not posted in the facility. This poses a potential health safety and or personal rights risk to residents in care.
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Type B
11/07/2025
Section Cited
CCR87468(c)(2)(A)

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87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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RCD stated they will have the RCFE complaint poster placed up. A picture will be sent to CCL as proof of correction by POC date.
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This requirement was not met as evidence by LPA observation. The licensee did not comply with the section cited above in that the RCFE complaint poster was not posted at the facility. This poses a potential health safety and or personal rights 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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2025 03:00 PM - It Cannot Be Edited


Created By: Mary Garza On 10/25/2025 at 03:15 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: MARBELLA VISALIA
FACILITY NUMBER: 547200844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87405(d)(1)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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RCD stated they will update the board in the kitchen to include type of diet, food texture type and allergies. An in-sevice will be completed with all kitchen staff and care staff. In-service sign in sheet and traiing material will be sent to CCL as proof of correction.
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 This requirement was not met as evidence by residents file review. The licensee did not comply with the section cited above in that review of special incident reports disclosed R3 had an allergic reaction on 5/14/25 and R1 had medication in their room unlocked and accessible on 5/15/25. This poses a potential health safety and or personal right risk to residents in care.
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Type B
11/07/2025
Section Cited
CCR87468.1(a)(3)

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87468.1 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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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RCD stated that gate and lock will be removed by maintenence.RCD stated they will also have staff remove knobs/place a locking mechanism on stove when not in use. Pictures will be provided to CCL by POC date as proof of correction.
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This requirement was not met as evidence by LPA observations on 6/10/25 and 10/25/25. The licensee did not comply with the section cited above in that a gate with lock to kitchenette preventing access to food/drink and posing a tripping hazard observed in memory care. This poses a potential health safety and or personal rights 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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2025


LIC809 (FAS) - (06/04)
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