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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547200844
Report Date: 12/30/2025
Date Signed: 12/30/2025 12:45:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/17/2025 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20251217153636
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: 57DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Resident Care Director: Britney PolmanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff is disclosing personal information regarding the residents

Staff is not properly reporting incidents involving the residents
INVESTIGATION FINDINGS:
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On 12/30/25 at 9:00 am Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Resident Care Director (RCD) Britney Polman.

The Department conducted an interviews with facility staff.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued.

Exit interview conducted. A copy of this report was distributed to Resident Care Director which confirms signature of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/17/2025 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20251217153636

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: 57DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Resident Care Director: Britney PolmanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff is mishandling the residents medications
INVESTIGATION FINDINGS:
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On 12/30/25 at 10:30 am Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Resident Care Director (RCD) Britney Polman.

The Department interviewed facility staff, and reviewed resident MAR's. LPA observed from the Assisted Living Med Tech Room R1's medication: Naproxen 500 mg tablet. Take 1 tablet by mouth as needed for pain. Start date is 12/1/25. Per MAR 13 staff initialed as taken sucessfully by R1. Per bubble pack of above medication, 14 tablets were punched out. Per medication count, 1 tablet over was punched out.

Based on observation, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficincies are being cited and civil penalty issued Per Title 22 Regulations.

Exit interview conducted. A copy of this report with appeal rights were distributed to Resident Care Director which confirms signature of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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 3
Control Number 24-AS-20251217153636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MARBELLA VISALIA
FACILITY NUMBER: 547200844
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2025
Section Cited
CCR
87465(a)(4)
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a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(4) The licensee shall assist residents with self-administered medications as needed.

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Licensee agrees that all Med-Tech staff complete medication training. Licensee agees to submit completion documents to CCLD by POC due date.
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Based on records reviewed and interviews conducted, R1’s medication count is not accurate and medication administered does not match the MARS, which poses an immediate Health & Safety risk to the residents.
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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: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3