Quail Park Retirement Village

Allegation investigated: Staff did not ensure that facility elevators are operable.

On 3/23/2026, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct a subsequent complaint inspection to deliver findings. LPA met Health/Wellness Director Crystal Alaniz and announced the purpose of the visit. Executive Director Trevin Willis was contacted and arrived a short time later. The Department investigated the allegations listed above. Based on interviews with Administrator, staff and residents, the facility has been working with TK Elevator Corporation to fix the elevator since December 2025. TK Elevator Corporation has come out several times to resolve the issue, and the elevator was operable for short periods but stopped working again. Repair is ongoing and the facility has another elevator available for use. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 23, 2026 · control 24-AS-20260217161135

Type of visit: Case Management - Deficiencies

On 3/23/2026, Licensing Program Analyst (LPA) K.Kaur arrived unannounced for complaint inspection and conducted a case management in conjunction. LPA met Health/ Wellness Director Crystal Alaniz and Executive Director Trevin Willis. During the course of the complaint investigation it was discovered Resident (R1) was stuck in the elevator and the facility failed to report the incident to CCLD. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator including discussing the plan of corrections. Report signed on-site. Printed copy provided with 809D page and appeal rights.the state’s words, verbatim · CDSS document, Mar 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 27, 2026

87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident…etc This requirement is not met as evidenced by: Facility failed to report incident of Resident (R1) being stuck in the elevator.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: LPA and Administrator reviewed reporting requirements and discussed incidents that should be reported. POC completed during visit.

Type of visit: Required - 1 Year

On 9/8/2025, Licensing Program Analyst (LPA) J. Leffall 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 Trevin Willis and Health and Wellness Director Crystal Alaniz. LPA conducted a tour of the facility with Health & Wellness Director, Crystal Alaniz LVN and Administrator Trevin Willis. 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 at a range of 109.9.4 F to 117.3 F in 5 apartments. Kitchen toured, 2-day perishable and 7-day nonperishable food observed. Medications were stored in a locked Medication cart. Laundry room and maintenance rooms were toured that contained locked with chemicals. LPA observed housekeeping carts had chemicals that was locked. 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. 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. No deficiencies issued during today's inspection. LPA is requesting the following documents be submitted to the Fresno CCL office by 9/22/2025: 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. A copy of this report was issued to Administrator whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) K. Kaur arrived at the facility to conduct a case management. LPA met with VP of Operations Edward Silva and Resident Care Manager, Crystal Alaniz. During the course of a complaint investigation other deficiencies were observed. During the course of a complaint investigation the following was discovered. Facility was limiting and preventing resident (R1) from receiving visitors. LPA provided PIN 21-48-ASC regarding the rights or residents; regarding the POA and conservators. Facility was informed they could not deny visitors. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Apr 18, 2025

87468.1 Personal Rights of Residents in All Facilities (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: Based on interviews Facility limited and prevented resident (R1) from receiving visitors which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: Licensee agrees to provide in service training for all staff on personal rights and submit training when completed.

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff are serving the residents expired food Staff are mishandling the resident's medications

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with administrator. LPA delivered the following findings. Based on observations the facility had expired food. Medication audit revealed residents’ medication was not logged in the Centrally Stored Medication and Destruction Record (CSMDR). The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Civil penalty issued due to repeat violation. Exit interview was conducted with Administrator and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 17, 2024 · control 24-AS-20231030162407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Jan 18, 2024

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on observation the facility had expired food in the kitchenthe state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: Administrator to ensure facility food expiration dates are reviewed on an on-going basis. In-service training will need to be provided to kitchen staff and submitted to CCLD by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Jan 18, 2024

87465(h)(6) (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained …. This requirement was not met as evidenced by: Medication audit reviled (R1) resident’s medication was not logged in the centrally stored list.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: Administrator to provide in-service training to med-techs and submit proof of training to CCLD by due date.

Allegation investigated: Licensee does not maintain the facility in good repair

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit to deliver findings. LPA met with Administrator Lenette Otero-Gross and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Based on observation and interviews with residents no issues have been observed that require repair or attention. Interview was conducted with Resident (R1) who stated kitchen sink was repaired recently. Work order was reviewed which indiacted the order was submited and completed on 1/16/2024. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 17, 2024 · control 24-AS-20231120132803

Type of visit: Required - 1 Year

On 12/20/2023, 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 Lenette Otero-Gross LPA conducted a tour of the facility and reviewed resident and staff files. 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 12/27/2023: 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 Administrator. Report signed on-site; a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2023