547201356-1-17-2024-24-AS-SMOA-D23LUN-20240202080413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547201356
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:50:16 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
10/30/2023 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20231030162407

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: 111	DATE:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Administrator Lenette Otero-Gross		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff are serving the residents expired food
Staff are mishandling the resident's medications

INVESTIGATION FINDINGS:

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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.

Based on observations the facility had expired food. Medication audit revealed residents’ medication was not logged in the Centrally Stored Medication and Destruction Record (CSMDR). The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Civil penalty issued due to repeat violation.

Exit interview was conducted with Administrator 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: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20231030162407

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: 01/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2024 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator to ensure facility food expiration dates are reviewed on an on-going basis. In-service training will need to be provided to kitchen staff and submitted to CCLD by due date.
	8 9 10 11 12 13 14	Based on observation the facility had expired food in the kitchen	8 9 10 11 12 13 14
Type A 01/18/2024 Section Cited CCR 87465(h)(6)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Administrator to provide in-service training to med-techs and submit proof of training to CCLD by due date.
	8 9 10 11 12 13 14	Medication audit reviled (R1) resident’s medication was not logged in the centrally stored list.	8 9 10 11 12 13 14

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: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

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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
10/30/2023 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20231030162407

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:	DATE:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Administrator Lenette Otero-Gross		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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9

Staff do not keep the facility free from pests
Staff have inadequate record keeping for the residents
Staff are not properly trained

INVESTIGATION FINDINGS:

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

The Department investigated the allegations listed above. Based on observation and interviews the facility did not have any pests. The facility does have a monthly servicing for pests. LPA reviewed staff files which had required documentation. 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: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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