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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209004
Report Date: 02/06/2024
Date Signed: 02/06/2024 02:32:55 PM


Document Has Been Signed on 02/06/2024 02:32 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: 103DATE:
02/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jeff MoyerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Health and Safety inspection. LPA met with and explained the reason for the visit with Administrator (AD) Jeff Moyer.

On 2/5/2024, the facility submitted a Special Incident Report (SIR) resulting in Resident (R1) experiencing an unwitnessed fall in private apartment. 911 was called and R1 was taken via ambulance for medical evaluation. Additionally, on 2/5/2024, the facility submitted a Death Report for R1.

During this visit, LPA toured the facility with AD. LPA requested and was provided copies of R1's file.

There were no citations during this inspection.

An exit interview was conducted and a copy of this report was provided to AD, whose signature confirms receipt.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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