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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 01/24/2023
Date Signed: 01/25/2023 01:14:41 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
09/19/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220919113811
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: 120DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Paul Anderson, Administrator/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff failed to meet resident's diabetic needs, resulting in hospitalization's
Facility staff restrained resident, resulting in injury
Resident is left soiled for extended periods of time
Facility staff are not safeguarding resident's property
Resident was not afforded dignity
INVESTIGATION FINDINGS:
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On 01/24/23, Licensing Program Analyst (LPA), L. Salazar arrived at the facility unannounced to conduct the required 10-day site visit. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Facility census is 93 in Assisted Living (AL) and 27 in Memory Care.

During the investigation, LPA conducted records review and interviews. Based on the information received, Resident R1 required a level of diabetic care needs that were not being provided, resulting in two hospitalization's.

A review of R1's file and physician's report indicates R1 is confused/disoriented & has aggressive/inappropriate behaviors. Records review and interviews reveal that staff would hold R1's hands/arms to avoid being hit, attempting to assist with R1's care needs. LPA's observation of records and pictures show injuries occurred to R1's arms and hands.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
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 6
Control Number 24-AS-20220919113811
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
VISIT DATE: 01/24/2023
NARRATIVE
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(Continued from 9099)

Interviews and records review evidence that R1 required care and supervision for incontinence care that was not provided by staff due to resident's refusal and cognitive mental state at the time. R1 was left soiled for several hours, on more than one occasion, while facility waited for assistance from R1's family.

Records review and interviews evidence R1 did not have the initial personal property inventory list LIC621 , which is required at the time of admission. R1's walker was missing and a sheet set for R1's bed was also missing.

Interviews evidence R1 was sent out to the hospital, with their lower body wrapped in only a sheet. R1 had no under garments on under the sheet, resulting in R1 being naked and possibly exposed.

Based on the: LPA’s records review, interviews and observation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. If not corrected, the violation will have a direct and immediate risk to the health and safety, or personal rights of resident's in care.

In accordance with the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 is being assessed in the amount of $500.

An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided at the time of visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 24-AS-20220919113811
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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2023
Section Cited
HSC
1569.49(c)(1)
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§1569.49 Civil penalties
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(1) Any violation that the department determines resulted in the injury or illness of a resident.
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Administrator provided LPA with a Diabetic policy/plan covering procedures effective 08/2022. An in-service training was completed with all Memory Care staff on 01/23/23. LPA received signed training attendance logs evidencing the training.
**POC Cleared**
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This requirement was not met as evidenced by LPAs review of hospital and facility records evidencing R1 was not receiving the required blood sugar readings and or insulin injection per the physician's orders, resulting in hospitalization on two occasions. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care. A civil penalty in the amount of $500 is being assessed. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care.
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Type A
01/25/2023
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator will provide additional dementia training with an emphasis on how staff will handle behaviors including aggressiveness and sun downing.
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This requirement was not met as evidenced by LPAs observation of pictures, records review and interviews. R1's hands/arms were held while staff were attempting to assist in daily living needs. This poses an immediate risk to resident's in care.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 24-AS-20220919113811
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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87625(b)(3)
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(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator will provide incontinence training to all staff with an emphasis on resident's with dementia and behaviors.
*POC due date 02/10/2023*
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This requirement was not met aas evidenced by LPAs interviews and records review that incontinence care was not provided by staff due to resident's refusal and cognitive mental state at the time. R1 was left soiled for several hours, on more than one occasion, while facility waited for assistance from R1's family.
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Type B
02/03/2023
Section Cited
CCR
87218(a)
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87218 Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153 (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.
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Administrator will create an additional resident reocrds checklist that ensures residents receive all the LIC required documents. Administrator will provide checklist by POC due date of 02/10/23.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 24-AS-20220919113811
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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...,
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Administrator will conduct an all staff in service reviewing the full regulation 87468.1. Administrator will send a sign in sheet evidencing staff have reviewed and understand the regulation. Plan of Correction due 02/10/23.
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This requirement was not met as evidenced by LPA's interviews with staff and reporting party that resident was sent to hospital via EMS with only a sheet (naked) wrapped around their lower body.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
09/19/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220919113811

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: 120DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Paul Anderson, Administrator/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff failed to seek timely medical attention for resident's UTI
Facility staff neglected resident, resulting in multiple falls
Facility staff left resident outside in the heat for extended period of time
INVESTIGATION FINDINGS:
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On 01/24/23, Licensing Program Analyst (LPA), L. Salazar arrived at the facility unannounced to conduct the required 10-day site visit. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Facility census is 93 in Assisted Living (AL) and 27 in Memory Care.

During the investigation, LPA conducted records review and interviews. Based on the information received, although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. Exit interview conducted and copy of report was left with Administrator. No deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6