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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547200844
Report Date: 12/03/2025
Date Signed: 12/05/2025 10:25:41 AM

Unfounded


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
11/24/2025 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20251124130557
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: 46DATE:
12/03/2025
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Vivian Villegas and Isabel CervantesTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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Resident sustained an injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility.
During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Resident sustained an injury while in care is UNFOUNDED. The evidence from the investigation indicated that the resident did not sustained injury while in care. This agency has investigated the complaint alleging (Resident sustained an injury while in care). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
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
11/24/2025 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20251124130557

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: 46DATE:
12/03/2025
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Vivian Villegas and Isabel CervantesTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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Staff did not ensure reporting requirements were followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Xiong conducted a complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The evidence from the investigation indicated that a report was not generated and sent to licensing for an incident that occurred in April of 2025. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
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-20251124130557
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: 12/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. LPA observed during an investigation that an indicent was not reported to Community Care Licensing.
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Per Interim Executive Director/Administrator, an inservice training will be conducted by the POC date.
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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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3