157209146-2-17-2026-24-AS-SMOA-DRFMBD-20260219082745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209146
Report Date: 01/31/2026
Date Signed: 02/17/2026 01:18:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2025 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20251211100546

FACILITY NAME:	QUALITY CARE ASSISTED LIVING		FACILITY NUMBER:	157209146
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	2607 MT. VERNON AVENUE		TELEPHONE:	(661) 871-8133
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93306
CAPACITY:	54	CENSUS: 41	DATE:	01/31/2026
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Facility staff, Nancy Cudal		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not arrange, or assist in arranging, for medical care for a resident in care
Residents are not accorded safe, healthful and comfortable accommodations
Facility staff did not ensure supplies necessary for personal care was readily available to each resident
Facility staff are administering medications that have not been authorized by the person's physician.
Facility staff did not receive appropriate training

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to investigate the above allegations. LPA met with facility facility staff Nancy Cudal, and explained the purpose of today's visit.

Regarding the allegation Facility staff did not arrange, or assist in arranging, for medical care for a resident in care. Resident 1 was refusing physical therapy in the past. Resident 1 is now receving physical therapy. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2025 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20251211100546

FACILITY NAME:	QUALITY CARE ASSISTED LIVING		FACILITY NUMBER:	157209146
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	2607 MT. VERNON AVENUE		TELEPHONE:	(661) 871-8133
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93306
CAPACITY:	54	CENSUS: 41	DATE:	01/31/2026
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Facility staff, Nancy Cudal		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not take appropriate measures to safeguard residents' cash resources

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to investigate the above allegations. LPA met with facility facility staff Nancy Cudal, and explained the purpose of today's visit.

Regarding the allegation Facility staff did not take appropriate measures to safeguard residents' cash resources. Resident 1's funds funds were reviewed on 12/29/2025. The facility could not provide receipts for Resident 1's spent funds. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview conducted with facility staff Nancy Cudal, and copy of report provided

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20251211100546

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: QUALITY CARE ASSISTED LIVING	FACILITY NUMBER: 157209146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/14/2026 Section Cited CCR 87217(g)(1)	1 2 3 4 5 6 7	87217 Safeguards for Resident Cash, Personal Property, and Valuables (g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following:(1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Facility Administrator will provide receipts and updated purchase ledger to LPA by POC date of 02/14/2026.
	8 9 10 11 12 13 14	Based on observation the facility staff was not keeping accurate record on a ledger documenting resident 1's purchases, which poses a potential, health, safety, or personalm rights risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 24-AS-20251211100546

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: QUALITY CARE ASSISTED LIVING	FACILITY NUMBER: 157209146
	VISIT DATE: 01/31/2026

NARRATIVE

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Regarding the allegation Residents are not accorded safe, healthful and comfortable accommodations. Resident 1 communicated during two visits to the facility one on 12/29/2025, and 01/31/2026 that they are doing ok, and safe at the facility. LPA observed during a visit to the facility on 01/31/2026 Resident 1's room appears clean, they were watching television and appeared to have clean clothing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Facility staff did not ensure supplies necessary for personal care was readily available to each resident. During visits to the facility on 12/29/2026, and 01/31/2026, Resident 1 does have personal care items including deodorant, toothbrush, and lotion readily available. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Facility staff are administering medications that have not been authorized by the person's physician. LPA reviewed resident 1's prescribed medication list. LPA observed staff 1 assisting facility residents with medications. LPA reviewed Resident 1's Centrally Stored Medication record provided to the facility by pharmacy. Resident 1 is being given all prescribed medication.Staff 1 has required training to assist residents with prescribed medications. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Facility staff did not receive appropriate training. LPA reviewed resident 1's prescribed medication list. LPA observed staff 1 assisting facility residents with medications. LPA reviewed Resident 1's Centrally Stored Medication record provided to the facility by pharmacy. Resident 1 is being given all prescribed medication. Staff 1 has required training to assist residents with prescribed medications. Staff 1 has all required training to provide care to residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with facility staff Nancy Cudal, and copy of report provided

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4