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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209004
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:02:32 PM


Document Has Been Signed on 04/02/2024 02:02 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: 100DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Jeff MoyerTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (AD), Jeff Moyer and Health Service Director (HSD) Karen Sutherland.

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

It was reported that between 2/23/24 – 2/25/24 Resident (R1) did not receive as needed (PRN) medication as ordered. The facility did not update R1’s MAR to reflect the changes made by the hospice agency on 2/23/24.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A Civil Penalty is being assessed for a repeat violation.








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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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 04/02/2024 02:02 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
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: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2024
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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Upon discovery of the medication error, S1 was removed from the schedule pending an internal investigation. LPA reviewed a correction Action Form which documents the discharge/termination of S1 effective 3/8/24. POC CLEARED.
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Licensee did not ensure that R1’s medications were received as ordered by the physician. New orders were provided to the facility which were not inputted to the MAR. R1 did not receive medications as ordered. 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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