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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209004
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:13:37 AM


Document Has Been Signed on 02/12/2024 10:13 AM - 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: 102DATE:
02/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Administrator, Jeff MoyerTIME COMPLETED:
10:20 AM
NARRATIVE
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On 02/12/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Jeff Moyer

The purpose of this visit is to follow up on incident reports submitted to the Fresno CCL office.

It was reported that on 01/09/2024, facility staff administered medication to R1 outside of the parameters set by R1’s physician.

LPA also followed up on an incident that occurred regarding bruising to R2’s arms.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jeff Moyer, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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Document Has Been Signed on 02/12/2024 10:13 AM - 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 AT SHANNON RANCH
FACILITY NUMBER: 547209004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by:
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Facility monitored R1's blood pressure throughout the night. Additionally, S1 received medication training and was pulled from administering medication until the retraining was complete. POC CLEARED.
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Based on interview and record review, the licensee did not comply with section 87465 when facility staff administered medication to R1 outside of the parameters set by R1’s physician, this is an immediate health and safety risk 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) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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