107208838-2-27-2024-24-AS-SPIY-D2WNS4-20240229094232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 02/27/2024
Date Signed: 02/27/2024 09:56:54 AM

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
01/26/2024 and conducted by Evaluator Miriam Flores

COMPLAINT CONTROL NUMBER: 24-AS-20240126102342

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: 47	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Constance Peters		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff did not provide adequate food service to residents.
Staff did not notify resident's authorized representative of a change in resident’s condition.
Staff did not assist residents with bathing in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to deliver findings on this investigation. LPA met with Facility Administrator, Constance Peters and announced the purpose of the visit.

LPA conducted interviews, observations, and record reviews.

Regarding staff did not safeguard resident's personal belongings. LPA conducted interviews, record review and LIC621 form. There was no supportive documentation found on file to support that resident's belongings were not safeguard.

Regarding staff did not provide adequate food service to residents. Based on conducted observations, file reviews, and interviews this allegation was found unsubstantiated.

Continue 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20240126102342

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: 02/27/2024

NARRATIVE

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Regarding staff did not notify resident's authorized representative of a change in resident's condition. Based on record review, review of the LIC602A form, and interviews there was not enough evidence on file to support that staff did not notify resident's authorized representative of a change in resident's condition.

Staff did not assist residents with bathing in a timely manner. Based on conducted observations and interviews, there was no evidence found that staff are not assisting residents with bathing in a timely manner.

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 Facility Administrator, Constance Peters. A copy of this report was provided to the Administrator, along with the appeals rights.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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