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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 05:52:11 PM

Unsubstantiated


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:
04:28 PM
MET WITH:Administrator, Frances HernandezTIME COMPLETED:
05:44 PM
ALLEGATION(S):
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9
Resident fell resulting in an injury due to care and supervison.
Staff not seeking medical attention for resident in a timely manner.
Resident's medication was not properly administered by staff.
Staff forced resident to take medication.

INVESTIGATION FINDINGS:
1
2
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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 investigation records were reviewed and interviews with staff were completed. Administrator confirmed that R1 had a history of falls. R1 was on hospice and was not sent out for these falls. Injuries were treated by hospice. Although the allegation occurred it was not due to lack of care and supervision of resident. LPA reviewed R1’s file for medications that were being taken. MARS were reviewed for the months of October through December 2021 which shows that R1 was receiving medications as prescribed. R1’s file contained a prescription from R1’s PCP to crush R1’s medications. Although the allegations may or may not have occurred the perponderance of evidence does not meet the Departments standard. The above allegations are UNSUBSTANTIATED. Exit interview completed. A copy of this report was given.
Unsubstantiated
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)
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