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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:30:08 AM

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
07/05/2023 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20230705155208
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: 116DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff hit residents arm
Staff forcibly pulled a residents hair
Staff speak inappropriately to residents in care
INVESTIGATION FINDINGS:
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On 08/17/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Director of Residential Services Shellie Whitlock and Administrator Paul Anderson.

During the course of the investigation record were reviewed and interviews were conducted. S1 had hit R1 and R2’s arm to get the residents’ attention. S1 spoke inappropriately to R1 and R3 when assisting the residents. S1 had pulled R2’s hair when R2 was trying to get out of the commonly used bathroom.

Based on record reviewed and interviews conducted, the preponderance of evidence standard has been met,therefore, the above allegations are found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator, whose signature confirm receipt of this report.
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: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20230705155208
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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities(a)(1) Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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Facility conducted an internal investigation and Administrator stated S1 have been terminated on 07/13/23 and all staff in-service training on Abuse was completed on 07/06/23, 07/07/23, 07/10/23, and on 07/20/23. Copies of S1 termination, all staff in-service training, and staff attendance for in-service training was received. POC cleared during visit.
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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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
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