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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209004
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:26:33 PM


Document Has Been Signed on 03/21/2024 03:26 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: 101DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Administrator, Jeff MoyerTIME COMPLETED:
03:41 PM
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On 03/21/2024, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct an annual inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Jeff Moyer.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, showers were equipped with non-slip floors. Hot water measured between 108 degrees F and 110.9 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 05/23/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 01/04/2024.

LPA reviewed staff and client records. Medications reviewed. First Aid Kit contained the required supplies.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/04/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was 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: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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