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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:57:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
10/13/2023 and conducted by Evaluator Miriam Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231013160821
FACILITY NAME:MAGNOLIA CROSSINGFACILITY NUMBER:
107208838
ADMINISTRATOR:PETERS, CONSTANCEFACILITY TYPE:
740
ADDRESS:32 W SIERRA AVETELEPHONE:
(559) 765-4916
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:60CENSUS: 46DATE:
12/08/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Constance PetersTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not administer resident's medications as prescribed
Staff do not assist resident in receiving physical therapy as needed
Staff do not assist resident with mobility needs
INVESTIGATION FINDINGS:
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On 12/08/2023, Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to deliver findings on the allegations listed above. LPA met with Facility Administrator Constance Peters to discuss the elements of the allegations.

Regarding the allegation, staff do not administer resident’s medication as prescribed. Based on interviews and record reviews, it is unclear weather or not R1’s medication was not administered as prescribed. LIC602A physician’s report state R1 can leave the facility unsupervised and able to administer own prescription medication. R1 has prescribed medication that facility cannot administer without physician’s orders.


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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
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 3
Control Number 24-AS-20231013160821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MAGNOLIA CROSSING
FACILITY NUMBER: 107208838
VISIT DATE: 12/08/2023
NARRATIVE
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Regarding the allegation, staff do not assist resident in receiving physical therapy as needed. Based on interviews and record review, it is unclear weather or not staff assisted resident in receiving physical therapy as needed. R1 was discharged from physical therapy on 8/29/23 and reassessed for physical therapy on 10/25/23.

Regarding the allegation, staff do not assist resident with mobility needs. Based on interviews and record review, it is unclear weather or not staff do not assist resident with mobility needs. Physician’s orders for electric mobility device was fill; electric mobility device is pending delivery.

The Department has investigated the above allegations. 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.

No Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Administrator, Constance Peters. A copy of this report along with appeals rights provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
10/13/2023 and conducted by Evaluator Miriam Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231013160821

FACILITY NAME:MAGNOLIA CROSSINGFACILITY NUMBER:
107208838
ADMINISTRATOR:PETERS, CONSTANCEFACILITY TYPE:
740
ADDRESS:32 W SIERRA AVETELEPHONE:
(559) 765-4916
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:60CENSUS: 46DATE:
12/08/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Constance PetersTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff do not meet resident’s modified dietary needs
INVESTIGATION FINDINGS:
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2
3
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5
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On 12/08/2023, Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to deliver findings on the allegation listed above. LPA met with Facility Administrator, Contance Peters to discuss the elements of the allegation.

Regarding the allegation, staff do not meet resident’s modified dietary needs. Interviews and record reviews were conducted.

Based on the information received, we have found that the complaint was UNFOUNDED, meaning that the allegations are false, or are without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted with Administrator and a copy of this report was provided at the time of visit. No deficiencies cited.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3