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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201356
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:01:56 PM

Document Has Been Signed on 11/29/2021 02:01 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 RETIREMENT VILLAGE, LLCFACILITY NUMBER:
547201356
ADMINISTRATOR:EGURROLA, THERESAFACILITY TYPE:
740
ADDRESS:4520 W CYPRESS AVETELEPHONE:
(559) 624-3500
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 175CENSUS: 109DATE:
11/29/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Theresa Egurrola, AdministratorTIME COMPLETED:
02:15 PM
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On 11/29/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA met with Theresa Egurrola, Administrator.

LPA conducted a tour with Administrator and Hector Castanon, Engineering Director. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer available for visitors and residents. Facility staff was observed with mask on. LPA observed residents in various areas of the facility and physically distanced 6 feet apart.

Fire extinguisher observed to be last serviced 11/08/2021. Food supply was checked and there appeared to be an adequate supply.

LPA toured residents’ rooms to be adequately lit and furnished. Bathrooms are observed with trash cans with no lid. Hand washing posting was not observed in bathroom sinks. LPA observed a 30-day PPE supplies.

A sample residents have updated emergency contact information. Staff records were reviewed for infection control training.

No deficiencies issued during this inspection.

Exit interview was conducted. Licensee will submit the following requested forms/information to Fresno CCL by: 12/05/21: Lic 308, Lic 500, Lic 610E, Lic 9020, updated Liability Insurance. LPA received copy of Administrator Certificate during facility inspection. Administrator was informed that as a COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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