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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 05/26/2021
Date Signed: 06/07/2021 02:10:40 PM

Substantiated


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
12/10/2020 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20201210164226
FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:CHAPMAN, MICHAELFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Executive Director, Michael Chapman TIME COMPLETED:
05:04 PM
ALLEGATION(S):
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Staff did not notify the authorized representative of a change in resident's health condition.
Staff did not provide supporting care and supervision to meet the needs of resident receiving home health care.
INVESTIGATION FINDINGS:
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On 05/26/2021, Licensing Program Analyst (LPA) L. Salazar and Kelly McClurg arrived to the facility unannounced to deliver findings on the above allegations.

During the course of the investigation, LPA conducted interviews and records review of the Home Health care plan notes that indicate the level of care for the Restricted Health Condition that Resident R1 requires. LPA requested communication logs evidencing the care the facility has provided under the Home Health care plan. LPA requested documentation from Executive Director evidencing the effort to contact the family regarding the change of condition for R1, however, the facility was unable to provide.

The Department investigated the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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-20201210164226
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 PLACE
FACILITY NUMBER: 157208940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2021
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Resident Care manager has established procedures with home health care. A plan of care has been established for each resident located in the wellness office. Facility care conference is established. This plan includes a collaborative meeting with the resident's responsible party, home health care agency and facility. *Deficiency cleared*
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This requirement was not met as evidenced by: interviews with staff and reporting party. Facility was unable to provide documentation supporting that contact was made to residents responsible party Power Of Attorney (POA) received notification of the change of condition.
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Type B
05/26/2021
Section Cited
CCR
87463(c)
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Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
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Director of resident services has created a documented in electronic telecommunication system which will alert Director 30 days prior to assessment due date and will conduct a joint meeting with all parties involved to include Home Health agency, responsible party and ED.
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This requirement was not met as evidenced by: Administrator stated he did not have a meeting with resident, resident's representative, staff and a representative from the home health
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2