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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 09/28/2022
Date Signed: 10/03/2022 03:52:56 PM


Document Has Been Signed on 10/03/2022 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:ANDERSON, PAULFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: 119DATE:
09/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Paul Anderson, Executive Director TIME COMPLETED:
11:15 AM
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On 09/28/22, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit. LPA was greeted by Executive Director, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Assisted Living census is 92 and Memory Care has a census of 27.

The purpose of LPA's visit is to deliver Resident R1's file that was obtained on 09/21/22. LPA will return at a later date. No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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