107208838-7-18-2023-24-AS-SPIY-CTVQ8A-20230719115626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 07/17/2023
Date Signed: 07/18/2023 09:47:23 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
06/20/2023 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230620122450

FACILITY NAME:	MAGNOLIA CROSSING		FACILITY NUMBER:	107208838
ADMINISTRATOR:	RANCOUR, MANDY		FACILITY TYPE:	740
ADDRESS:	32 W SIERRA AVE		TELEPHONE:	(559) 765-4916
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	60	CENSUS: 42	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Constance Peters		TIME COMPLETED:	05:09 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff using profanity toward residents
Staff is falsifying resident records
Staff is engaging in inappropriate activites infront of residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA Williams met with Administrator, Constance Peters.

LPA Williams conducted interviews, observations, and record revie

In regards to staff using profanity towards residents, LPA interview four residents. Resident 4, 7, and 8 reported they have not seen or heard staff use profanity toward residents. Resident 2 reported hearing someone use profanity while they were in their room, but did not see if the individual was a resident or staff or who they were speaking to.

In regards to staff falsifying records. LPA spoke with Staff 1 who reported if residents decline to eat or want to eat in their room, they informs the manager.

*Continued on LIC 9099-C*

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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 4

Control Number 24-AS-20230620122450

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
	VISIT DATE: 07/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In regards to staff is engaging in inappropriate activities in front of residents, R5, R6, R7, and R8 all reported they have not witnessed any inappropriate behavior from staff.

The Reporting Party was anonymous and no contact information was provided to the Department for follow up and clarification regarding dates, times, and individuals involved regarding the 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.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/20/2023 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230620122450

FACILITY NAME:	MAGNOLIA CROSSING		FACILITY NUMBER:	107208838
ADMINISTRATOR:	RANCOUR, MANDY		FACILITY TYPE:	740
ADDRESS:	32 W SIERRA AVE		TELEPHONE:	(559) 765-4916
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	60	CENSUS: 42	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Constance Peters		TIME COMPLETED:	05:09 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Multiple Residents developed stage 4 pressure injury because staff do not reposition residents.
Staff not providing residents with meals
Resident's dog disrupts other residents during day and night time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA Williams met with Administrator and discussed the purpose of the visit.

LPA Williams conucted interviews and observations.

In regards to multiple residents developed stage 4 pressure injuries because staff do not reposition residents, LPA reviewed facility records, hospice records, and observations of Resident 1 (R1), Resident 2, Resident 3, and Resident 4. LPA Williams did not observe any observable wounds nor where there any mention of staged wounds in their records. LPA interviewed Witness 1 (W1) who has visited Resident 1 for approximately three years and reported not hearing or observing any wounds. Additionally, W1 reported staff and themselves reposition R1.

*Continued on LIC 9099-C*

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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 4

Control Number 24-AS-20230620122450

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
	VISIT DATE: 07/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In regards to staff not providing residents with meals, on 7/6/2023 and 7/17/2023, LPA Williams observed staff preparing meals and residents eating in the dining hall. LPA Williams interviewed interview Staff 1 who reported meals are provided to resident in their room, if they want, and in the dining hall. Resident 5, Resident 6, Resident 7, and Resident 8 all reported knowing when meal times were and stated staff will come to their door to remind them if they do not come out to the dining hall.

In regards to resident's dog disrupts other residents during the day and night time, the facility policy allows pets. During the LPA's two visit no dog was heard barking. According to the Administrator a walking program is established for the dog and the residents family will assist as needed. Administrator reported any concerns regarding the dog is brought to the attention of the resident and their family.

The Reporting Party was anonymous and no contact information was provided to the Department for follow up and clarification regarding dates, times, and individuals involved regarding the allegations.

This agency has investigated the complaint alleging multiple residents developed stage 4 pressure injury because staff do not reposition residents, staff not providing residents with meals, resident's dog disrupts other residents during day and night time. We have found that the complaint was UNFOUNDED, meaning it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4