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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209004
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:58:24 PM


Document Has Been Signed on 03/14/2022 03:58 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 AT SHANNON RANCHFACILITY NUMBER:
547209004
ADMINISTRATOR:MOYER, JEFFFACILITY TYPE:
740
ADDRESS:3330 & 3440 W FLAGSTAFF AVETELEPHONE:
(559) 527-8245
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:150CENSUS: 81DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Administrator Jeff Moyer and Health Director Marissa Stanley TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced Case Management visit regarding an elopement that occurred on 8/4/21. LPA discussed the purpose of the visit. LPA met with Administrator Jeff Moyer and Health Director Marissa Stanley.

R1 exited the facility which set off the alarm. Staff immediately counted residents and located R1 two houses down from the facility. Facility staff were able to see resident from the window of the facility and responded to bring R1 back.

No deficiencies were observed.

An exit interview was conducted with the Administrator and a copy of this report was emailed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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