<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206596
Report Date: 08/08/2024
Date Signed: 08/08/2024 06:52:31 PM


Document Has Been Signed on 08/08/2024 06:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:QUAIL PARK MEMORY CARE RESIDENCESFACILITY NUMBER:
547206596
ADMINISTRATOR:OTERO-GROSS, LENETTEFACILITY TYPE:
740
ADDRESS:5050 TULARE AVENUETELEPHONE:
(559) 624-3560
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:44CENSUS: 29DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Lauri Aguilar and Health and Wellness Director Kassandra Hernandez TIME COMPLETED:
07:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/8/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Executive Director Lauri Aguilar and Health and Wellness Director Kassandra Hernandez

LPA conducted facility tour with Health and Wellness Director. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. The tour continued to the facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA toured locked offices and storage rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. At 10:01 AM LPA observed laundry detergent, Bleach, and all-purpose cleaner in room #19. LPA observed Fire extinguisher was serviced on 8/15/2023. LPA toured two Locked laundry rooms. Facility cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. LPA observed delayed egress doors. Doors and passageways are unobstructed throughout the facility and to the outside. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes.



At 3:02 PM LPA reviewed residents’ medication with MARS and centrally stored list and observed 3 missed medication dosages for two residents. PRN medication was not logged with required information. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. At 4:23PM LPA observed 1 out of 5 staff files were missing Tuberculosis documentation. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified.

Continued to next page.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


Document Has Been Signed on 08/08/2024 06:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: QUAIL PARK MEMORY CARE RESIDENCES
FACILITY NUMBER: 547206596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 6 residents rooms were observed with chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
1
2
3
4
Items were removed or locked during inspection. Administrator to visit all resident rooms to ensure no chemicals are kept in rooms. Administrator to submit a report of findings to LPA when completed.
Type A
Section Cited
CCR
87465(a)(4)
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in 3 out of 3 medications were missed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit plan of intent by due date. Administrator will complete medication audit, medication training, & process for documenting medication administration. Plan will include the date all phases of plan will be complete. Once all areas are reviewed documentation of records will be submitted to CCLD
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 08/08/2024 06:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: QUAIL PARK MEMORY CARE RESIDENCES
FACILITY NUMBER: 547206596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
87465(c)(3)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review of the MAR, medications, and CSMDR the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. PRN medications are being documented on the routine MAR, identified as PRN being administrated in place of routine medication due to medications not being refilled. PRN medications that are being given are not documented with required information.
POC Due Date: 08/29/2024
Plan of Correction
1
2
3
4
Administrator to conduct an audit to determine if resident medications are ordered/filled on time and submit results of audit to CCLD. Administrator to review process/procedures of refills and provide in service training to staff and submit records when completed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 08/08/2024 06:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: QUAIL PARK MEMORY CARE RESIDENCES
FACILITY NUMBER: 547206596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment (b)The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 5 residents did not have records of TB test/results which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
1
2
3
4
Administrator to schedule doctor’s appointment for tuberculosis by due date and submit results when completed
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MEMORY CARE RESIDENCES
FACILITY NUMBER: 547206596
VISIT DATE: 08/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/15/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Executive Director. Report signed on-site; a copy of this report, 809D with appeal rights was provided. Civil penalty assessed due to repeat citation.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7