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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547201356
Report Date: 04/10/2023
Date Signed: 04/10/2023 01:32:40 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
02/01/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20230201161921
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: 109DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Administrator Lenette Otero-GrossTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Medication records are not properly documented.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with administrator. LPA delivered the following findings.

The Department investigated the allegations listed above. Based on observation and record review a medication was not documented in the centrally stored prescription medications list.

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 with Administrator
and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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
02/01/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20230201161921

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: 109DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Administrator Lenette Otero-GrossTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is storing medication without a label.
Facility is not administering medication as prescribed.
INVESTIGATION FINDINGS:
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9
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13
Licensing Program Analyst (LPA) K. Kaur conducted a subsequent complaint inspection to deliver findings. LPA met with Administrator Lenette Otero-Gross and Health and Wellness Director Megan Mike and explained the purpose of the visit and reviewed the elements of the allegation. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observation and records reviewed the facility medications all contained medication labels at time of review and based on records review and interviews conducted medications are being administered as prescribed.

Based on the interviews conducted, the allegations listed above 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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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-20230201161921
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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2023
Section Cited
CCR
87465(h)(6)
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87465(h)(6) (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained ….

This requirement was not met as evidenced by:
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Administrator shall insure going forward record of centrally stored prescription medications for each resident is maintained
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Based on records review a medication was not documented in the centrally stored prescription medications list.
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7
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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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3