Quail Park at Shannon Ranch

Allegation investigated: Staff do not ensure residents physician reports are updated Licensee does not ensure staff are properly trained Staff do not ensure medications are dispensed as prescribed Staff do not ensure medications are properly managed and accounted for Staff do not ensure adequate care supervision is provided resulting in resident falls

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. LPA met with Wellness Nurse Cynthia Fumagalli and spoke to Administrator Kim Santos on the phone and informed them the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations.The Department has investigated the complaint alleging: Staff do not ensure residents physician reports are updated, Licensee does not ensure staff are properly trained, Staff do not ensure medications are dispensed as prescribed, Staff do not ensure medications are properly managed and accounted for, and Staff do not ensure adequate care supervision is provided resulting in resident falls. Based on the interviews conducted and/or records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2026 · control 24-AS-20260108093931

Type of visit: Required - 1 Year

Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct annual inspection. LPA met with Wellness Nurse Cynthia Fumagalli and spoke to Administrator Kim Santos on the phone and informed them the purpose of the visit. LPA toured the facility with staff. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 07/2025. Water temperature observed to measure at 115 degrees F. No deficiencies were observed.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Staff did not meet resident's oral hygiene needs while in care.

On 01/15/2025, Licensing Program Analyst's (LPA) Sarah Hurt and Shawna Doucette arrived to the facility unannounced to deliver findings on the above allegation. LPA met with Facility Administrator, Kim Santos, and stated the purpose of the visit. Regarding the allegation Staff did not meet resident's oral hygiene needs while in care. Reporting Party stated upon further review Resident 1 lived at a different facility location. Resident 1 was not a resident at this facility. Based on the information received, we have found that the complaint is Unfounded, meaning that the allegation is false, could not have happened, and/or is without reasonable basis, therefore, we have dismissed the complaint. Nothe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 24-AS-20251025043019

Allegation investigated: Staff stole resident’s belongings. Staff go through resident’s personal belongings. Resident’s door in disrepair. Facility elevator is in disrepair.

On 01/15/2025, Licensing Program Analyst's (LPA) Sarah Hurt and Shawna Doucette arrived to the facility unannounced to deliver findings on the above allegation. LPA met with Facility Administrator, Kim Santos, and stated the purpose of the visit. Regarding the allegation Staff stole resident’s belongings. The reporting party stated that approximately one month after the resident moved into the facility, Resident 1 reported missing cash from their phone wallet case. Resident 1 reportedly believed they had approximately $140–$200 and later discovered only $40 remaining. The reporting party stated the resident did not leave the facility independently, did not drive, and was not visiting nearby businesses. At the time, the resident lived alone in a studio apartment (Room 227) in assisted living. Unsubstantiated The reporting party stated the resident reported the missing money to facility staff. Reporting party further stated a second incident of missing money occurred at a later date. Two cameras were reportedly installed in the resident’s room in July; however, no theft activity was observed on camera. The reporting party stated the resident had frequent visitors, including friends and family members. LPA interviewed other residents currently residing at the facility. No residents reported staff stealing personal belongings or witnessing staff take resident property. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff go through resident’s personal belongings. The reporting party stated they believed someone had gone through Resident 1's belongings after money was reported missing on more than one occasion. Reporting party stated resident 1 kept their phone wallet with them most of the time, except while sleeping or showering. The reporting party did not witness staff going through the resident’s belongings and did not provide dates or times when this allegedly occurred. Reporting party stated Resident 1 had frequent visitors, including friends, family members, and acquaintances. LPA interviewed residents currently residing at the facility. No residents reported staff entering their rooms without permission or going through their personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Resident’s door in disrepair. During the inspection, LPA observed the resident’s door. The door was observed to be operational at the time of inspection. The door does need to be pulled tightly to close. The reporting party or the facility did not provide specific dates, work orders, or documentation showing the door was in disrepair during the resident’s occupancy. LPA did not observe any other resident doors being nonfunctional or unsecured. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Facility elevator is in disrepair. The facility elevator was in disrepair for an extended period. The facility maintenance staff did immediately attempt to repair but parts needed to be ordered. The facility has multiple elevators that can be used by residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with facility Administrator Kim Santos. A copy of this report was provided at the time of visitthe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 24-AS-20250908153035

Allegation investigated: Questionable Death.

On this date, Licensing Program Analyst (LPA), L. Xiong arrived unannounced to deliver findings on the above allegation. LPA stated the purpose of the visit and requested to meet with the Executor Director. LPA met with Kim Santos. During this investigation, the Department conducted interviews and reviewed records. It was found that facility staff were not responsible for medication management and were not required to perform regular scheduled checks. The Department has investigated the complaint alleging: Questionable Death. We have found that the complaint was UNFOUNDED. An exit interview was conducted. A copy of this report was discussed and provided to Kim Santos. Unfoundedthe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 24-AS-20250822154708

Allegation investigated: Staff did not ensure resident's medication is administered as prescribed Staff do not follow reporting requirements Staff did not ensure resident's showering needs are met

On 01/26/2025, Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to deliver findings on the above allegation. LPA met with Facility Administrator, Kim Santos, and stated the purpose of the visit. Regarding the allegation Staff did not ensure resident's medication is administered as prescribed. Resident 1's MAR documents multiple missed medications including on 09/18/25 p.m., and 09/19/2025 both a.m. and p.m. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Substantiated Regarding the allegation Staff do not follow reporting requirements. Facility staff and Reporting party both stated Staff 1 was not reporting all incidents involving residents medications, administering of medications, and communication with home health to resident 1's responsible party. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation Staff did not ensure resident's showering needs are met. The facilities care notes document Resident 1 was not consistently showered. The care notes document three showers, and one shower refusal during the months of August, September, and October 2025. The care notes document showers on 08/05/2025, 09/01/2025, and 10/06/2025, and the one refusal on 09/29/2025. The facilities shower log does not have resident 1 listed Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are cited Per Title 22 Regulations. Exit interview conducted with facility Administrator Kim Santos. A copy of this report was provided at the time of visitthe state’s words, verbatim · CDSS document, Jan 15, 2026 · control 24-AS-20250911082640

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 27, 2026

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1's MAR documents multiple missed medications including on 09/18/25 p.m., and 09/19/2025 both a.m. and p.m., which poses is an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator will conduct audits with facility Health and Wellness director to ensure all medications are being administered to facility residents, and submit proof to LPA by POC date of 01/27/2026..

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 9, 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. The following requirement has not been met as evidenced by: Resident 1's Responsible party was not notified of communication with home health agency effecting Resident 1's care, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator will conduct communication with facility Health and Welness director on the subject of reporting and communication with resident responsible parties, and submit to LPA by 02/09/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Feb 9, 2026

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.. The following requirement has not been met as evidenced by: Resident 1 was not being assisted as needed with showers, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator will conduct training with facility staff on documenting shower logs including refusals, and submit to LPA by POC date of 02/09/2026.

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Les Xiong conducted the complaint investigation visit to the facility. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation:Facility is in disrepair is UNFOUNDED. The evidence from investigation indicated there were a/c units not functioning but the facility responded timely and had the units repaired timely while portable units were provided and used during the repair. This agency has investigated the complaint alleging (Facility is in disrepair). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Oct 8, 2025 · control 24-AS-20251001083755

Type of visit: Required - 1 Year

Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct annual inspection. LPA met with Administrator Jeff Moyer on the phone and inform him the purpose of the visit. LPA toured the facility with staff. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 04/2024. Water temperature observed to measure at 115 degrees F. No deficiencies were observed.the state’s words, verbatim · CDSS document, Mar 28, 2025

Allegation investigated: Facility staff handled resident in a rough manner. Facility staff inappropriately spoke to resident in care.

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. LPA met with Office Manager, Peggy Silviera and Administrator, Jeff Moyer on the phone and informed them the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Facility staff handled resident in a rough manner, and Facility staff inappropriately spoke to resident in care. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 7, 2025 · control 24-AS-20240718093610

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a case management follow up visit. LPA met with and explained the reason for the visit with Administrator (AD) Jeff Moyer. On 2/6/2024, LPA conducted a Health & Safety case management visit to obtain information regarding an incident reported and death report which had been submitted by the facility as required. The Department has reviewed the information obtained. There were no violations identified during the investigation. No citations issued. An exit interview was conducted with AD. A copy of this signed report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (AD), Jeff Moyer and Health Service Director (HSD) Karen Sutherland. The purpose of this visit is to follow up on an incident report submitted to the Fresno CCL office. It was reported that between 2/23/24 – 2/25/24 Resident (R1) did not receive as needed (PRN) medication as ordered. The facility did not update R1’s MAR to reflect the changes made by the hospice agency on 2/23/24. A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A Civil Penalty is being assessed for a repeat violation. 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, Jeff Moyer, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 2, 2024

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by: Licensee did not ensure that R1’s medications were received as ordered by the physician. New orders were provided to the facility which were not inputted to the MAR. R1 did not receive medications as ordered. This is an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2024

Plan of correction: Upon discovery of the medication error, S1 was removed from the schedule pending an internal investigation. LPA reviewed a correction Action Form which documents the discharge/termination of S1 effective 3/8/24. POC CLEARED.

Type of visit: Required - 1 Year

On 03/21/2024, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct an annual inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Jeff Moyer. LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, showers were equipped with non-slip floors. Hot water measured between 108 degrees F and 110.9 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Fire extinguisher serviced on 05/23/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 01/04/2024. LPA reviewed staff and client records. Medications reviewed. First Aid Kit contained the required supplies. LPA is requesting the following documents be submitted to the Fresno CCL office by 04/04/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Jeff Moyer, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Mar 21, 2024

Type of visit: Case Management - Incident

On 02/12/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Jeff Moyer The purpose of this visit is to follow up on incident reports submitted to the Fresno CCL office. It was reported that on 01/09/2024, facility staff administered medication to R1 outside of the parameters set by R1’s physician. LPA also followed up on an incident that occurred regarding bruising to R2’s arms. A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. 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, Jeff Moyer, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Feb 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 13, 2024

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with section 87465 when facility staff administered medication to R1 outside of the parameters set by R1’s physician, this is an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Facility monitored R1's blood pressure throughout the night. Additionally, S1 received medication training and was pulled from administering medication until the retraining was complete. POC CLEARED.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Health and Safety inspection. LPA met with and explained the reason for the visit with Administrator (AD) Jeff Moyer. On 2/5/2024, the facility submitted a Special Incident Report (SIR) resulting in Resident (R1) experiencing an unwitnessed fall in private apartment. 911 was called and R1 was taken via ambulance for medical evaluation. Additionally, on 2/5/2024, the facility submitted a Death Report for R1. During this visit, LPA toured the facility with AD. LPA requested and was provided copies of R1's file. There were no citations during this inspection. An exit interview was conducted and a copy of this report was provided to AD, whose signature confirms receipt.the state’s words, verbatim · CDSS document, Feb 6, 2024