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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208838
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:47:14 PM

Document Has Been Signed on 07/06/2023 02:47 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
CCLD Regional Office, 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: 43DATE:
07/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Administrator, Constance PetersTIME COMPLETED:
12:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted a visit at the facility in response to a resident document received. LPA Williams met Administrator, Constance Peters and discussed the purpose of the visit.

LPA Williams reviewed medical assessments for Resident 1 (R1) and Resident 2 (R2), who are admitted to the memory care facility. R1's recent medical assessment was dated 1/14/2022 and R2's recent medical assessment was dated 5/23/22. Based on Title 22 regulation, R1's medical assessment had to be renewed by 1/14/2023 and R2's by 5/23/2023.

Administrator reported the medical assessment would be completed by 7/14/2023.

Based on record review a deficiency is being cited on the attached LIC 809-D page.

An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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Document Has Been Signed on 07/06/2023 02:47 PM - It Cannot Be Edited


Created By: Darius Williams On 07/06/2023 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MAGNOLIA CROSSING
FACILITY NUMBER: 107208838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited

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(c) Licensees who ... retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ... done at least annually, ...

This requirement was not met evident by:
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Based on LPA's record review, the Licensee did not ensure 2 residents in Dementia care had an annual medical assessment completed, which cause a potential health and safety risk to persons 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:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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