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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201356
Report Date: 11/07/2022
Date Signed: 11/07/2022 12:15:40 PM

Document Has Been Signed on 11/07/2022 12:15 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:OTERO-GROSS, LENETTEFACILITY TYPE:
740
ADDRESS:4520 W CYPRESS AVETELEPHONE:
(559) 624-3500
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 175CENSUS: 102DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lenette Otero-Gross, Administrator and amantha Torres, Health and Wellness Director TIME COMPLETED:
11:35 PM
NARRATIVE
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On 11/07/22, 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 Lenette Otero-Gross, Administrator and Crystal Alaniz, Resident Care Coordinator. LPA conducted a tour with Administrator and Resident Care Coordinator. Later during tour Samantha Torres,Health and Wellness Director arrived.

Visitor log-in/temperature check was observed upon entry. Facility staff was observed with mask on. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer available for visitors and residents. LPA observed residents in various areas of the facility and physically distanced 6 feet apart. COVID-19 related signs and cough etiquette postings was observed.

Fire extinguisher observed to be last serviced 11/08/21. Food supply was checked and there appeared to be an adequate supply. Hand washing posting was observed in bathroom sinks. LPA observed a 30-day PPE supplies. All residents' room are single occupant. LPA toured residents’ rooms to be adequately lit and furnished. All bathrooms are observed with securely fastened grab bars. Bathrooms are observed with trash cans with no lid. LPA and Administrator observed cleaning chemical bottles stored and unlocked under resident’s bathroom sink. LPA and Administrator observed resident’s medications stored in bathroom shelve and under resident’s bathroom unlocked.

LPA checked residents’ locked medications. A sample of resident records reviewed to have updated emergency contact information. Staff records were reviewed for good health and current CPR first aid.

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

Exit interview was conducted. A plan of correction was developed and reviewed with the Administrator. A copy of this report and appeal rights was provided to the Administrator. Licensee will submit the following requested forms/information to Fresno CCL by: 11/14/22: Lic 308, Lic 500, Lic 610E and updated Liability Insurance.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 11/07/2022 12:15 PM - It Cannot Be Edited


Created By: Mai Yang On 11/07/2022 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: QUAIL PARK RETIREMENT VILLAGE, LLC
FACILITY NUMBER: 547201356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and Administrator observed at 09:40AM, cleaning chemical bottles stored and unlocked under R1’s accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Administrator immediately removed the chemical bottles into locked staff medication room. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and Administrator observed R1’s medications stored in resident’s under bathroom sink and shelf unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Administrator immediately removed the medications into locked staff medication room. POC cleared during visit.
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 Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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