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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206596
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:18:12 PM


Document Has Been Signed on 05/31/2022 03:18 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 MEMORY CARE RESIDENCESFACILITY NUMBER:
547206596
ADMINISTRATOR:EGURROLA, THERESAFACILITY TYPE:
740
ADDRESS:5050 TULARE AVENUETELEPHONE:
(559) 624-3560
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:44CENSUS: 26DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Theresa EgurrolaTIME COMPLETED:
03:20 PM
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On 5/31/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator Theresa Egurrola.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

LPA observed 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 07/28/21. All resident’s room toured and observed to be adequately furnished and lit. All residents' room are single occupant. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with no lid. Hand washing posting observed by bathroom sinks.

LPA checked residents’ locked medications. A sample of resident records reviewed to have updated emergency contact information. Staff records were reviewed for good health and current CPR first aid.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/6/22. The following updated forms were requested: Lic 308, Lic 309, Lic 610E, Lic 9020, and current liability insurance. LPA received copy of current Administrator certificate during inspection.

A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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