547206596-8-15-2023-24-AS-KKAR-CUR3QN-20230815182724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547206596
Report Date: 08/15/2023
Date Signed: 08/15/2023 06:28:59 PM

Document Has Been Signed on 08/15/2023 06:28 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 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: 26	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Executive Director Megan Mike		TIME COMPLETED:	06:45 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 8/15/2023, 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, Acting Administrator Megan Mike and Resident Care Manager Melissa Segura. LPA conducted facility tour with Administrator. 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. At 10:16 AM LPA observed the Ice Machine to have brown buildup underneath the door lift area. LPA toured a few 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. Hot water temperature was tested between 117.2 degrees F and 120 degrees in several shared resident bathrooms. At 11:08 AM LPA observed Fire extinguisher in hallway to be expired with a service date of 7/20/2022. LPA toured two Locked laundry rooms. 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 3:48 PM LPA reviewed residents’ medication with MARS and centrally stored list and observed medication count was short for one resident and over for another. LPA observed the centrally stored list was incomplete. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. 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 Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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Document Has Been Signed on 08/15/2023 06:28 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: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(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 2 out of 2 medications reviews which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit a plan in writing for correction of error, including complete medication audit, medication training, & process for documenting medication administration. Plan should include Continued maintenance. Plan will include the date all phases of plan will be complete.

Type A

Section Cited

CCR

87203

87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1. Fire extinguisher was expired with a service date of 7/20/2022, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator had fire extinguishers serviced during inspection. Citation cleared during inspection

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2023 06:28 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: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(29)

General Food Service Requirements

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 Ice Machine observed to have buildup in need of cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Ice Machine was emptied and cleaned during inspection. Facility to submit pictures as POC

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above in 2 out of 2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure all current centrally stored list are completed accurately and completely. Administrator shall provide training and complete centrally stored list and submit records/pictures to CCLD by due as POC.

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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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: 08/15/2023

NARRATIVE

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Deficiency is 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 8/29/2023: 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 Administrator. Report signed on-site; a copy of this report, 809D with
appeal rights was provided. .

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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