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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208838
Report Date: 08/04/2023
Date Signed: 08/20/2023 04:17:11 PM


Document Has Been Signed on 08/20/2023 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MAGNOLIA CROSSINGFACILITY NUMBER:
107208838
ADMINISTRATOR:RANCOUR, MANDYFACILITY TYPE:
740
ADDRESS:32 W SIERRA AVETELEPHONE:
(559) 765-4916
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:60CENSUS: 41DATE:
08/04/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Constance Peters TIME COMPLETED:
04:00 PM
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On 08/04/2023, Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility LPA met with Facility Administrator Constance Peters and announced the purpose of the inspection.


LPA Hurt reviewed the facility Medication Administration Records. LPA Hurt observed the facilities medication tracking system is unorganized, missing medication technician signatures, documents extra medication technician signatures, documents crossed out information on the Medication administration record without documenting what happened in each instance.

LPA Hurt advised Administrator Constance Peters of the importance of correctly tracking, documenting, and storing all resident medications.


Technical Assistance provided.


Exit interview conducted with Administrator Constance Peters, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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