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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:24:59 PM


Document Has Been Signed on 02/06/2023 01:24 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: 122DATE:
02/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie Whitlock.TIME COMPLETED:
01:30 PM
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On 02/06/23, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management inspection regarding incident report received from facility on 1/25/23. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock.

The purpose of the today's visit is to follow up on the incident report that was submitted to department on 1/25/23 of incident occurred where medications was not administered. The department conducted interviews and reviewed records shown 30 residents did not receive residents' evening medications on 01/15/23.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. A copy of this report and appeal rights was provided via email. Report signed on site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/06/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited

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87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee stated all medication technician staffs has been retrained on administering medication on 01/31/23. Copies of trainings and rooster of staff attendance will be submitted to department by 02/07/23.
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Based on interviews and records review, the licensee did not ensure staff administer medications to 31 residents on the evening of 01/17/23 which poses an immediate health and safety risks to persons in care.
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A plan of correction of action plan the Licensee will take shall be submitted to CCL. POC shall include facility MAR to be reviewed by staff and ongoing staff trainings on administering medications. POC of action plan will be submitted to department by 02/07/23.

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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: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
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