107208838-2-21-2024-24-AS-MFLS-D2NUFQ-20240221143308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208838
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:33:15 PM

Document Has Been Signed on 02/21/2024 02:33 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	MAGNOLIA CROSSING		FACILITY NUMBER:	107208838
ADMINISTRATOR:	PETERS, CONSTANCE		FACILITY TYPE:	740
ADDRESS:	32 W SIERRA AVE		TELEPHONE:	(559) 765-4916
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	60	CENSUS: 46	DATE:	02/21/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Constance Peters		TIME COMPLETED:	02:45 PM

NARRATIVE

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This Licensing Program Analyst (LPA) M. Flores arrived unannounced to continue an annual inspection. LPA was allowed entry by Administrator, Constance Peters.

LPA completed record reviews for staff and resident files.

Deficiency are being cited in accordance with the California Code of Regulations, Title 22, see LIC809D.

The following updated forms are to be submitted to CCL by 02/27/24: LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, LIC999, and control of property.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed Administrator, Constance Peters whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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 02/21/2024 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 46 out of 60 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Administrator will provide training to Med Techs regarding the usage of the refrigerators in the medication room and Title22 regulation 87555(b)(25) by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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