547206596-12-21-2022-24-AS-SMOA-CMKMHL-20221229083739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547206596
Report Date: 12/21/2022
Date Signed: 12/21/2022 11:23:15 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/07/2022 and conducted by Evaluator Mai Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20221007131548

FACILITY NAME:	QUAIL PARK MEMORY CARE RESIDENCES		FACILITY NUMBER:	547206596
ADMINISTRATOR:	OTERO-GROSS, LENETTE		FACILITY TYPE:	740
ADDRESS:	5050 TULARE AVENUE		TELEPHONE:	(559) 624-3560
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	44	CENSUS: 25	DATE:	12/21/2022
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Administrator Lenette Otero-Gross and Health and Wellness Director Megan Mike		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained fracture and was hospitalized due to staff’s neglect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/21/22, Licensing Program Analyst (LPA), M. Yang arrived at the facility unannounced to deliver complaint finding and stated the purpose of the visit and granted entry. LPA met with Administrator Lenette Otero-Gross and Health and Wellness Director Megan Mike.

During the course of the investigation, the Department conducted interviews, records were reviewed and based on review, the preponderance of evidence standard has been met, therefore the allegation that Resident 1 (R1) sustained fracture and was hospitalized due to staff neglect is SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, a deficiency is being cited on the attached Lic 9099D. A violation regarding care and supervision warrants an immediate civil penalty. An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/07/2022 and conducted by Evaluator Mai Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20221007131548

FACILITY NAME:	QUAIL PARK MEMORY CARE RESIDENCES		FACILITY NUMBER:	547206596
ADMINISTRATOR:	OTERO-GROSS, LENETTE		FACILITY TYPE:	740
ADDRESS:	5050 TULARE AVENUE		TELEPHONE:	(559) 624-3560
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	44	CENSUS: 25	DATE:	12/21/2022
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Administrator Lenette Otero-Gross and Health and Wellness Director Megan Mike		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility increased resident’s admission rate without reason

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 24-AS-20221007131548

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/22/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times … competent to provide the services necessary to meet resident needs… staff shall be employed to ensure provision of personal assistance and care as required … the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met:	1 2 3 4 5 6 7	Adminsitrator stated all staff in-service traiing was completed per regulation guidelines on 10/27/22. The department received copies of the training and rooster of staff attendance during visit. POC cleared during visit.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, R1 sustained fracture while in care that required R1 to be hospitalization. Residents change of condition was not reported immediately which possess an immediately health and safety and personal rights risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

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