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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 06/29/2022
Date Signed: 06/29/2022 05:50:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20211021101417
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: 40DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Administrator, Frances HernandezTIME COMPLETED:
04:27 PM
ALLEGATION(S):
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Staff inappropriately handled residents
Staff used inappropriate words towards resident
INVESTIGATION FINDINGS:
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On 6/29/22 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to deliver findings on complaint. LPA was met by Administrator, Frances Hernandez. LPA explained reason for visit and was COVID pre-screened. LPA was permitted entry into facility. LPA toured facility inside and out. A health and safety check on residents were observed in common areas and in rooms.

During the investigation interviews were completed with staff and Administrator. S3 confirmed that S1 "was not approriately transferring R1" and that S1 "was agitated with R1" and "mad about having to work with them because R1 could be difficut at times". S1 was "aggressive in the way that they would sometimes talk to residents". Administrator stated "due to COVID staff was working in areas that they normally did not work and knew some of the staff were burnt out".

The allegations listed above are SUBSTANTIATED. The poponderance of evidence standard has been met. Per CA Title 22, deficiencies cited in the attached 809D. Appeal Rights given. Exit interview completed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20211021101417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAGNOLIA CROSSING
FACILITY NUMBER: 107208838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents.. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Administrator stated that they will complete staff traiining on Personal Rights with each household, with Ombudsman and will provide CCL copy of training materials and a sign ni sheet by POC date.
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This requirement was not met as evidence by: LPA's review of records, interviews with staff and Administrator which showed staff were shorthanded, working in areas they normally didn't and were "burnt out". S1 was transferring/talking to residents inappropriately. This posses a potential health and safety risk to residents in care.
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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 MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
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