Quail Park Memory Care Residences

Allegation investigated: Staff did not assist resident with ambulating Staff did not treat resident with dignity and respect Staff did not provide resident with refund

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. Administrator Crystal Alaniz was unavailable to meet. LPA met with staff Jessica Rodrigues and discussed the purpose of the visit and the elements of the allegations. LPA delivered the following findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed resident (R1) was bed bound and was assisted with a 2 to 3 person assist when ambulating. Based on interviews conducted, no instances where documented or observed of staff treating the resident without dignity or respect. On March 30, 2026, the facility issued a refund to residents POA. Based on these findings, the above allegations are UNSUBSTANTIATED. 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, Sep 24, 2026 · control 24-AS-20260325085414

Allegation investigated: Staff did not follow resident's diet plan

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent complaint inspection. LPA met with Administrator Crystal Alaniz 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 interviews conducted and records reviewed, the facility did not follow resident's diet plan. Per Doctor’s orders Resident (R1) should have been on a mechanically soft diet and resident was served items of the regular menu. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted 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 Substantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2026 · control 24-AS-20260325085414

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Sep 4, 2026

87555 General Food Service Requirements (b)The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Per Doctor’s orders dated 2/12/2026 Resident (R1) should have been on a mechanically soft diet and based on interviews conducted resident was served and fed by a staff food items of the regular menu.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Administrator agrees to review General Food Service Requirements regulations and submit statements stating their understanding of regulations and submit supporting documents regarding facility process/procedures that ensure the special diets are being adhered to.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

On 8/10/2026 Licensing Program Analyst (LPA) K.Kaur conducted an unannounced Case Management Annual Continuation visit. LPA arrived, introduced self, and stated purpose of visit. LPA met with interim Administrator Trevin Willis, to conduct visit. Annual continuation visit is being conducted to complete outstanding items from previous visit on 7/31/2026. Visit was a continuation for Medication audit, Fire drill, Restrictive Conditions service plans. Based on medication audit, R1 had two medications with missed dosage of medication. Centrally Stored Medication and Destruction Record was incomplete or medication was not logged. Last Fire drill was conducted on 7/23/2025. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Immediate Civil Penalty assessed for Repeat violation California Code of Regulation 87465(a)(4). Exit interview conducted and a plan of correction was reviewed and developed with Administrator Trevin Willis. 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, Aug 10, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 7/31/2026, 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. Executive Director/ Interim Administrator Trevin Willis was contacted and arrived a short time later. LPA conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. Outside gardening area toured. Locked offices and storage rooms toured. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Water temperature for four rooms was below or above the required temperatures. Unlocked hygiene items observed in Room #2. Resident’s door was wide open, allowing access to other residents. LPA toured Locked laundry room. Facility cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. LPA observed delayed egress doors. Doors and passageways are unobstructed throughout the facility and to the outside. The tour continued to the facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed an enclosed patio area with sufficient seating and shade for recreational purposes. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified. During file review it was observed that one staff member was not associated with the facility. Continued to LIC 809-C Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Immediate Civil Penalty assessed for caregiver background check. Due to time constraints LPA will return at a later date to complete the annual inspection. Exit interview conducted and a plan of correction was reviewed and developed with Administrator Trevin Willis. 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, Jul 31, 2026

Type of visit: Case Management - Deficiencies

On 5/21/2026, Licensing Program Analyst (LPA) K.Kaur arrived unannounced and conducted a case management – deficiencies visit in regards to a self-reported incident that occurred on 4/10/2026. LPA met with Executive Director Krystle Rodrigeuz and Resident Care Manager Javonna Davis. Based on incident report Resident (R1) was given extra doses of medication then prescribed and administered medication incorrectly due to MAR error. LPA discussed best practices and discussed 7 rights of medication administration. Deficiency is 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 staff. A copy of this report and appeal rights were discussed and provided to Staff, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, May 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 23, 2026

87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on incident report Resident (R1) was given extra doses of medication then prescribed and administered medication incorrectly due to MAR error.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator to provide a statement of intent regarding med-tech in service training. Administrator will conduct audit to ensure all residents E-MAR medications match prescribed medications. Administrator to submit proof of training and findings of audit when completed.

Type of visit: Required - 1 Year

On 8/19/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Inspection. LPA introduced self, stated purpose of visit, and allowed entry. LPA Medina conducted facility tour with Executive Director/Administrator, Lauri Aguilar. . Facility observed to be clean, odor free and a comfortable temperature. Residents observed within the community participating in various activities with staff, such as chair exercises, arts and crafts, and live music. Adequate seating available for all residents in all common areas. Kitchen toured, facility receives food delivery weekly. LPA observed a 2-day supply of perishable and 7-day supply of non-perishable food available as well as Emergency Supply food. Daily menus are posted in dining areas with alternate options available. LPA toured resident units #3, #14, #18, #19, #28, #0, #33, #39, all resident units observed to be furnished with individual cooling/heating units. Resident bathrooms observed to have grab bars near toilets, showers observed to have grab bars, skid resistant mats, and shower chairs. Water temperature measured between 108 - 119 degrees F. Facility is equipped with fire pull stations throughout both buildings. Fire extinguisher all have current service dates of 12/17/2024. Carbon monoxide detectors observed operational during today's visit. Last fire drill conducted on 7/23/25, according to facility records. Outside courtyard observed to have shade and seating available. No hazards available. LPA received copies of current Administrator Certificate, liability insurance, activities schedule, personnel roster and resident roster during facility inspection. LPA reviewed resident and staff files. No deficiencies observed.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Licensee does not ensure that there is sufficient staffing to meet the needs of residents in care. Residents are sustaining falls due to lack of staff supervision.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA met with Executive Director Lauri Aguilar and discussed the purpose of the visit and the elements of the allegations. LPA delivered the following findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed the facility had sufficient staffing to provide care although staff needs were changing due to census. Based on records reviewed no major raise in falls was found. Based on these findings, the above allegations are UNSUBSTANTIATED. 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, Dec 2, 2024 · control 24-AS-20240805092419

Allegation investigated: Residents are missing medications

Licensing Program Analyst (LPA) K. Kaur arrived at the facility to conduct an initial 10-day complaint inspection. LPA met with Executive Director Lauri Aguilar and discussed the purpose of the visit and the elements of the allegations. Health and Wellness Director Kassandra Hernandez joined a short time later. LPA delivered the following findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed it was discovered (R1) Residents are missing medications. Medication audit revealed residents’ medication was not logged in the MAR(s) or the Medication narcotics Log as given but pill count was short by 3. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Executive Director, a copy of this report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 17, 2024 · control 24-AS-20241016151014

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 18, 2024

87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Medication audit revealed (R1) resident’s medication pill count 3 pills that were missing and not documented administrated.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Administrator to provide a statement of intent regarding med-tech in service training and review the requirements of proper documentation to support medication pill count. Administrator to submit proof of training to CCLD by due date.

Type of visit: Required - 1 Year

On 8/8/2024, 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 Executive Director Lauri Aguilar and Health and Wellness Director Kassandra Hernandez LPA conducted facility tour with Health and Wellness Director. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. The tour continued to the facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA toured locked offices and storage rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. At 10:01 AM LPA observed laundry detergent, Bleach, and all-purpose cleaner in room #19. LPA observed Fire extinguisher was serviced on 8/15/2023. LPA toured two Locked laundry rooms. Facility cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. LPA observed delayed egress doors. Doors and passageways are unobstructed throughout the facility and to the outside. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. At 3:02 PM LPA reviewed residents’ medication with MARS and centrally stored list and observed 3 missed medication dosages for two residents. PRN medication was not logged with required information. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. At 4:23PM LPA observed 1 out of 5 staff files were missing Tuberculosis documentation. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified. Continued to next page. Deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 8/15/2024: 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, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Executive Director. Report signed on-site; a copy of this report, 809D with appeal rights was provided. Civil penalty assessed due to repeat citation.the state’s words, verbatim · CDSS document, Aug 8, 2024

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not administer resident’s medications as prescribed

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA met with Executive Director Lauri Aguilar and discussed the purpose of the visit and the elements of the allegations. Administrator Lennette arrived a short while later. LPA delivered the following findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed Staff did not administer resident’s medications as prescribed. Medication audit revealed residents’ medication was not logged in the Centrally Stored Medication and Destruction Record (CSMDR). CSMDR was incomplete and missing information. R1’s Medication count revealed extra pills based on records. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator, a copy of this report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 2, 2024 · control 24-AS-20240312124816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 3, 2024

87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Medication audit revealed (R1) resident’s medication pill count had an extra 28 pills in a packet that should have been given.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Administrator to provide a statement of intent regarding med-tech in service training and review the requirements of proper documentation to support medication pill count. Administrator to submit proof of training to CCLD by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Jul 9, 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 and or was incomplete.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Administrator to submit completed centrally stored records by due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst LPA K.Kaur conducted a Case Management to follow up on a SOC 341 submitted by the facility. LPA was met with Administrator Megan Mike. LPA discussed the purpose of the visit. LPA interviewed staff regarding incident. LPA will return at a later date to follow up on this incident once paperwork has been reviewed. An exit interview was conducted with Administrator. Report signed on-site; a copy of the report will be emailed due to technical difficulties.the state’s words, verbatim · CDSS document, Apr 24, 2024