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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208838
Report Date: 02/22/2022
Date Signed: 03/02/2022 04:59:49 PM


Document Has Been Signed on 03/02/2022 04:59 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: 37DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Administrator, Frances HernandezTIME COMPLETED:
01:12 PM
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On 2/22/2021, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by Administrator, Frances Hernandez. Due to facility having positive COVID staff/residents LPA conducted video tele-visit. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in common area and in room.

Mitigation plan was reviewed and approved. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff observed coming out of buildng without face coverings. Facility has designated visitation areas. Covered trash bins were not observed. LPA observed a 30 day supply of PPE and resident medications. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance. No deficiencies cited on todays inspection. TA's given for masking and trash bins.

A copy of this report will be emailed. A delivered and read receipt serves as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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