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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 02/21/2023
Date Signed: 02/21/2023 10:33:50 AM

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
01/09/2023 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230109110932
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: 34DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Administrator, Lai SaeteurnTIME COMPLETED:
10:47 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administering medication while under the influence
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/21/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations, LPA introdcued self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Lai Saeteurn.

During this investigation, LPA reviewed records and interviewed facility staff.

Based on interviews conducted, the allegation: Staff administering medication while under the influence is UNSUBSTANTIATED. 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.

No deficeincies issued during this inspection. Exit interview conducted. A copy of this report was dicussed and provided to Administrator, Lai Saereurn, whose signature on this form confirms receipt of this document.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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
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
01/09/2023 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230109110932

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: 34DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Administrator, Lai Saeteurn.TIME COMPLETED:
10:47 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication missing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/21/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations, LPA introdcued self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Lai Saeteurn.

During this investigation, LPA reviewed records and conducted interviews.

Based on interviews conducted and record review, it was determined that the medication for R1 was destoyed by faciltiy staff S2 and the hospice nurse. The agency has investigated the complaint alleging: medication missing. We have found the the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Lai Saeteurn, whose signature on this form confirms receipt of this document.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2