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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201356
Report Date: 11/07/2024
Date Signed: 11/21/2024 09:28:51 AM

Document Has Been Signed on 11/21/2024 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:QUAIL PARK RETIREMENT VILLAGE, LLCFACILITY NUMBER:
547201356
ADMINISTRATOR/
DIRECTOR:		SIDOTI,JAMESFACILITY TYPE:
740
ADDRESS:4520 W CYPRESS AVETELEPHONE:
(559) 624-3500
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 175CENSUS: 125DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Administrator James SidotiTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 11/07/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Administrator James Sidoti.

LPA conducted a tour of the facility with Health & Wellness Director Gus Chavez, LVN and Resident Care Manager Crystal Alaniz.

Tour was completed of the main two story building, the Enhanced assisted living building and the Independent cottages. The facility was free of passageway obstructions inside and outside. Common areas observed clean with sufficient seating. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured from 114.4 F to 119.1 F in various apartments.

Kitchen toured, 2-day perishable and 7-day nonperishable food observed. At 11:07 AM LPA observed buildup in crevices of ice machine and observed an ice cube that had brown substance. Medications were stored in a locked Medication cart. LPA observed the laundry room and maintenance rooms were unlocked with chemicals. LPA observed housekeeping carts had chemicals that was unlocked. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a sprinkler system with fire alarm. Staff files were reviewed to have First aid/CPR certification and required training.



Due to time constraints, LPA will return at a later date for an annual continuation.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/14/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Health & Wellness Director. Report signed on-site; a copy of this report was provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11/21/2024 09:28 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/07/2024 at 02:49 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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, interview, the licensee did not comply with the section cited above in 4 out of 4 areas; laundry room and maintenance rooms were unlocked with chemicals. Housekeeping cart had chemicals that were unlocked and several resident rooms had chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Staff locked chemicals immediately. Staff will follow up with maintenance regarding doors that were not locking and submit results to CCLD when corrected.
Type A
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

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 in 1 out of 1 Ice machine observed to have brown and pink buildup in crevices; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Staff immediately stopped use of ice and placed for deep cleaning. Dinning Director will look for deep cleaning services.
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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