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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 06/29/2020
Date Signed: 06/29/2020 03:37:41 PM



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
02/25/2020 and conducted by Evaluator Mary Garcia
COMPLAINT CONTROL NUMBER: 24-AS-20200225152800
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: 39DATE:
06/29/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Mandy RancourTIME COMPLETED:
03:26 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff improperly handled resident resulting in injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/29/2020 Licensing Program Analyst (LPA) M. Garcia conducted a tele-inspection (due to COVID 19 pre-cautionary measures) to deliver findings on the above complaint. LPA contacted facility Administrator, Mandy Rancour via telephone to disclose the findings of the allegation.

During the course of the investigation medical and facility records were reviewed and interviews were conducted. There is insufficient evidence to prove that the allegation did or did not occur, therefore the allegation is UNSUBSTANSIATED. An Exit Interview conducted with Adminitrator and a copy of this report via email with an electronic email read receipt confirms receipt of these documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mary GarciaTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
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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