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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201356
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:18:25 PM


Document Has Been Signed on 11/07/2022 01:18 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:QUAIL PARK RETIREMENT VILLAGE, LLCFACILITY NUMBER:
547201356
ADMINISTRATOR:OTERO-GROSS, LENETTEFACILITY TYPE:
740
ADDRESS:4520 W CYPRESS AVETELEPHONE:
(559) 624-3500
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:175CENSUS: 102DATE:
11/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Lenette Otero-Gross, Administrator and Samantha Torres, Health and Wellness DirectorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 11/07/22, Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Health and Safety Inspection. LPA introduced self, stated the purpose of the visit and met with the Lenette Otero-Gross, Administrator and Samantha Torres, Health and Wellness Director.

The purpose of the visit is to address two incidents that was reported to the department. The first incident that occurred on 11/01/22 where R1 money went missing from resident’s apartment. Interviews were conducted and records were obtained for S1 and R1. The information provide will be reviewed; a follow up case management will be conducted if necessary.

LPA address the second incident where there was a medication error. It was reported that on 10/07/22, R2 received medication Digoxin for 0.5 tablet and should have been administered 1 tablet. R2 did not received for six days medication: Atorvastatin and Metoprolol. R2 did not received for three days medication: Eliquis and Ezetimibe.

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.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 11/07/2022 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: QUAIL PARK RETIREMENT VILLAGE, LLC
FACILITY NUMBER: 547201356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Based on interview conducted and record review, the licensee did not comply with the section cited above when R2 was administered one medication in the wrong dosage, two medication was not administered to R2 for six days and two medications was not administered to R2 for three days. Interview with Administrator confirmed staff had administered a wrong dosage for one medication, two medications were not administered for six days and two medications were not administered for three days which poses an immediate health, safety or personal rights ricks to persons in care.
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Licensee agreed to submit documentation detailing steps the facility will take to ensure the requirements of Health-Related Services are met by the due 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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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