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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547200844
Report Date: 12/02/2025
Date Signed: 12/02/2025 10:33:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
11/16/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20251116222344
FACILITY NAME:MARBELLA VISALIAFACILITY NUMBER:
547200844
ADMINISTRATOR:RANCOUR, MANDYFACILITY TYPE:
740
ADDRESS:3120 W. CALDWELLTELEPHONE:
(559) 735-0828
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:72CENSUS: 48DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Resident Care Director Brittney Polman TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff are not keeping resident information/records confidential
INVESTIGATION FINDINGS:
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On 12/02/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct complaint visit to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Resident Care Director Brittney Polman.

During the course of the investigation, facility was toured and interviews were conducted. Based on interviews conducted, residents’ information is provided to outside medi-cal assisted agencies programs for referral to verify if the resident meets the programs requirements prior to the resident applying for the medi-cal assisted programs without resident’s knowledge. Residents are unaware of the programs until the outside agencies meet with the residents after the referral has been accepted for the initial enrollment process. Therefore, the allegation alleging staff are not keeping resident information/records confidential, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview was conducted. A copy of this report and appeal rights was provided to Resident Care Director Brittney Polman, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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-20251116222344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MARBELLA VISALIA
FACILITY NUMBER: 547200844
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2025
Section Cited
CCR
87506(c)
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87506 (c) All information and records obtained from or regarding residents shall be confidential.

This requirement was not met as evidence by:
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Written Plan of Correction shall be submitted to the Fresno CCL by POC due date 12/08/25.
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Based on interviews conducted, residents’ information are provided to outside medi-cal assisted agencies programs for referral to verify if the resident meets programs requirement without resident’s knowledge, 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2