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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201356
Report Date: 11/21/2024
Date Signed: 11/22/2024 08:11:34 AM

Document Has Been Signed on 11/22/2024 08:11 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:
11/21/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Administrator James Sidoti and Health & Wellness Director Gus ChavezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 11/21/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Continuation 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 during original visit on 11/7/2024 and observed over the counter medications in several residents’ rooms.

LPA reviewed resident files. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Medical Assessments are current with TB Clearance. LPA conducted a medication audit and no issues were observed.



Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with the Administrator. Report signed on-site, copy of report and appeal rights will be provided via email.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 11/22/2024 08:11 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/21/2024 at 02:41 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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

(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 in 3 out of 6 resident's rooms were observed with unlocked medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator agrees to schedule in-service training for all staff by due date and submit records when completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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