547201356-1-18-2023-24-AS-SMOA-CPL2JN-20230303162635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547201356
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:21:43 PM

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
12/05/2022 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20221205101506

FACILITY NAME:	QUAIL PARK RETIREMENT VILLAGE, LLC		FACILITY NUMBER:	547201356
ADMINISTRATOR:	OTERO-GROSS, LENETTE		FACILITY TYPE:	740
ADDRESS:	4520 W CYPRESS AVE		TELEPHONE:	(559) 624-3500
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	175	CENSUS: 107	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Administrator Lenette Otero-Gross		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are mismanaging resident's medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for a subsequent inspection.
LPA discussed the purpose of the visit and the elements of the allegations with administrator. LPA Interviewed
Staff and administrator.

The Department has interviewed staff and Administrator, toured the facility, and reviewed records. Based on a sample review of medication that was conducted, and files reviewed. R1 and R2 medication review revealed that medication was missed and or not properly handled. The department received a self- reported incident report from the facility regarding R3 Medication doses being incorrectly given.

The preponderance of evidence standard has been met, therefore the above allegations are found to be
SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted and appeal rights
were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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
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
12/05/2022 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20221205101506

FACILITY NAME:	QUAIL PARK RETIREMENT VILLAGE, LLC		FACILITY NUMBER:	547201356
ADMINISTRATOR:	OTERO-GROSS, LENETTE		FACILITY TYPE:	740
ADDRESS:	4520 W CYPRESS AVE		TELEPHONE:	(559) 624-3500
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	175	CENSUS: 107	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Administrator Lenette Otero-Gross		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not meet the qualifications to care and supervise residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit and conducted interviews
and reviewed records. LPA met with Administrator Lenette Otero-Gross and explained the purpose of the visit andreviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Administrator, staff were interviewed and based on interviews conducted and records reviewed facility is providing the necessary training to staff to care and supervise for resident in care.

Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove
that the alleged violations did or did not occur, therefore these allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20221205101506

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: QUAIL PARK RETIREMENT VILLAGE, LLC	FACILITY NUMBER: 547201356
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/19/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	The Administrator agrees to place checks to ensure if medication is missed by Med-Techs a lead person will review the medications and ensure they are dispensed in a timely manner to all residents. A re-training of all Med-Techs has already been completed on 1/5/2023 and all staff training will be completed by 1/27/23.
	8 9 10 11 12 13 14	Based on records reviewed and interviews, staff failed to administer medication to resident in care, which poses an immediate Health and Safety risk to the residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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