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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 03:48:22 PM


Document Has Been Signed on 05/31/2022 03:48 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrator Theresa EgurrolaTIME COMPLETED:
04:30 PM
NARRATIVE
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On 05/31/22, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management inspection regarding incident report received from facility on 04/07/22. LPA met Administrator Theresa Egurrola.

The purpose of the today's visit is to follow up on the incident report that was submitted to department on 04/07/22. Staff did not administer medications to five residents at 08:00 p.m. on 04/04/22. Staff signed off the electronic medication log stating staff administered medications when medications was not administered.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. A copy of this report and appeal rights 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)
Page: 1 of 2


Document Has Been Signed on 05/31/2022 03:48 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited

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87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:

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Based on interviews and records review, the licensee did not ensure staff administered medication at 8:00 p.m. to five residents on 04/04/22 which poses an immediate health and safety risks to persons in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2