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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:13:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
01/23/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230123092901
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: 127DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff failed to seek timely medical attention for resident fall.

Facility staff mismanaged residents medications.
INVESTIGATION FINDINGS:
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On 04/28/23, Licensing Program Analyst (LPA), M. Yang, arrived at the facility unannounced to deliver complaint findings for the above allegations. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock and discussed the purpose of the visit.

The Department conducted interviews with staff and reviewed records. Based on interviews conducted facility staff failed to seek medical attention in a timely manner after a resident’s unwitnessed fall that resulted in the resident sustaining a pelvic fracture. An Immediate Civil Penalty is being assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.

During the course of the investigation, records were reviewed, and interviews were conducted with staff. Based on interviews conducted staff had administered a medication that was not prescribed to the resident 1(R1).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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 4
Control Number 24-AS-20230123092901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MAGNOLIA PLACE
FACILITY NUMBER: 157208940
VISIT DATE: 04/28/2023
NARRATIVE
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Based on the interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See attached LIC 9099D form for deficiencies cited in accordance with Title 22 California Code of Regulations.

An exit Interview conducted. A copy of this report and Appeal Rights was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20230123092901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAGNOLIA PLACE
FACILITY NUMBER: 157208940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/11/2023
Section Cited
HSC
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required… The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement was not met as evidence by:
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Facility has agreed to provide an all care staff in-service training to review all aspects of care and supervision. A review of when to call for Emergency Medical Services will also be conducted by due date.
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Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above when
Resident 1 a non-verbal and paralyzed resident had an unwitnessed fall on 12/14/23 and was not sent to the hospital until 12/16/23 which poses/posed an immediate health, safety, or personal rights risk to persons in care.

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Administrator will submit staff attendance rooster which will include include date, signature of facility staff who attended and as well as a copy of training materials to CCLD via email by 05/11/23.
Type A
05/01/2023
Section Cited
CCR
87465(a)(5)(A)
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87465(a)(5)(A) Incidental Medical and Dental Care Facility staff…shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered… (A) Medications…prescribed for self-administration which have been authorized by the person's physician.

This requirement was not met as evidence by:
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Licensee shall have all med tech to be retrained on administering medication. Copies of trainings and rooster of staff attendance which will include signature of staff who attended and date. Trainings and rooster will be submitted to department by 5/11/23.
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Based on record reviewed and interviews conducted, the licensee did not comply with the section cited above when
staff administered Norco to resident 1(R1). Medication was not prescribed by the resident’s physician which poses/posed an immediate health, safety, or personal rights risks to the person in care.
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A plan of correction of an action plan the Licensee will take to ensure regulations are met. Action plan shall include double checking medications with MARs before administering medications to resident and ongoing staff trainings on administering medications. POC of action plan will be submitted to department via email by 5/1/23.
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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
01/23/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230123092901

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: 127DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not properly addressing insect infestation in facility.

Facility staff did not respond to resident's call button in a timely manner
resulting in residents death.


INVESTIGATION FINDINGS:
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On 04/28/23, Licensing Program Analyst (LPA), M. Yang, arrived at the facility unannounced to deliver complaint findings on the above allegations. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock and discussed the purpose of the visit.

During the course of the investigation, the department conducted interviews, toured the facility, and reviewed records. LPA toured the facility and observed no ants. Administrator stated ants were taken care immediately the same day when made aware of it. Based on the observation and interviews conducted, the above allegation staff are not properly addressing insect infestation in the facility is found to be UNSUBSTANTIATED.

The department conducted interviews with staff and reviewed records. Based on interviews conducted and record reviewed on facility staff did not respond to resident’s call button in a timely matter resulting in resident’s death. The preponderance evident has not been met. Therefore, based on interviews conducted and records reviewed, the above allegation is founded to be UNSUBSTANTIATED. An exit Interview conducted. A copy of this report was provided to Administrator, whose signature confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4