107208838-7-1-2020-24-AS-AXIG-BR4NXH-20200701105107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208838
Report Date: 06/29/2020
Date Signed: 07/01/2020 10:45:41 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
01/02/2020 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20200102100443

FACILITY NAME:	MAGNOLIA CROSSING		FACILITY NUMBER:	107208838
ADMINISTRATOR:	RANCOUR, MANDY		FACILITY TYPE:	740
ADDRESS:	32 W SIERRA AVE		TELEPHONE:	(559) 765-4897
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	60	CENSUS: 37	DATE:	06/29/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Mandy Rancour		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Residents are not getting their needs met.
Medications are left unlocked.
Moldy bread is served to the residents.

INVESTIGATION FINDINGS:

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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 Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
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)

Page: 1 of 3

Control Number 24-AS-20200102100443

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: 06/29/2020

NARRATIVE

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Continued from page 1.

Staff denied having any knowledge of resident(s) not receiving care in emergency situations. No information available at the time of the investigation to show that resident(s) were denied emergency care around the time of the allegation. There is insufficient information to support the allegation.

Staff denied observing medications accessible to residents in staff office. Medication carts observed by LPA to be locked. No information to indicate that expired medications were not destroyed around the time of the allegation. There is insufficient information to support the allegation.

Staff denied serving moldy bread to residents. Residents denied being served moldy bread. Family denied having seen or heard of moldy bread being served. There is insufficient information to support the allegation that moldy bread was served to residents around the time of the allegation.

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 Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
01/02/2020 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20200102100443

FACILITY NAME:	MAGNOLIA CROSSING		FACILITY NUMBER:	107208838
ADMINISTRATOR:	RANCOUR, MANDY		FACILITY TYPE:	740
ADDRESS:	32 W SIERRA AVE		TELEPHONE:	(559) 765-4897
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	60	CENSUS: 37	DATE:	06/29/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Mandy Rancour		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident records are not kept confidential.
Food service is inadequate.

INVESTIGATION FINDINGS:

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Staff denied resident records being exposed, including resident MARs & medication instructions. Resident records observed by LPA to be in cabinet in locked laundry room. MARs & medication instructions observed by LPA to be in locked medication cart.

Staff, residents, & family stated that resident food portions served are reasonable. Meal observed by LPA had portions that appeared to meet or exceed USDA Basic Food Serving Sizes. Food observed available for seconds. Resident stated that they were allowed seconds or substitutes.

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

Exit interview conducted with Administrator Mandy Rancour.
Report provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2020

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3