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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 06/27/2020
Date Signed: 06/29/2020 07:54:35 AM



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
01/07/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20200107124522
FACILITY NAME:MAGNOLIA CROSSINGFACILITY NUMBER:
107208838
ADMINISTRATOR:RANCOUR, MANDYFACILITY TYPE:
740
ADDRESS:32 W SIERRA AVETELEPHONE:
(559) 765-4897
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:60CENSUS: 37DATE:
06/27/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mandy RancourTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents sustained multiple falls resulting in injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this investigation by phone and correspondence.

On this date Licensing Program Analyst (LPA) K. Mcclurg conducted a telephone interview with Administrator Mandy Rancour. LPA notified Administrator that the purpose of this call was regarding a Complaint investigation.

The Department conducted staff & resident interviews & record reviews.

Continued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2020
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 2
Control Number 24-AS-20200107124522
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: 06/27/2020
NARRATIVE
1
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5
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7
8
9
10
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32
Staff confirm that R1 & R2 each had a fall that resulted in injury around the time of the allegation. R1 & R2 received medical attention. Staff conducted checks on R1 & other designated rounds to supervise residents. Based on all information available at the time of the allegation, there was no information to indicate that incidents occurred due to negligence or lack of supervision.

The Department has investigated the above allegations. Based on interviews & record reviews, the Department has found the allegations were unsubstantiated.

Exit interview conducted with Administrator Mandy Rancour.
Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2