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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 03/19/2024
Date Signed: 03/22/2024 03:13:56 PM


Document Has Been Signed on 03/22/2024 03:13 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
SIERRA CASCADE AC/SC, 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: 125DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
12:00 PM
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On 03/19/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct a case management-deficiency visit. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock.

During the annual inspection on 03/11/24, LPA Kaur reviewed residents’ medications and MARs. Record shown that multiple residents’ medications were not recorded on the resident’s Centrally Store Medication Log.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

An exit interview was 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: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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 03/22/2024 03:13 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
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
87465(h)(6)

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87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…

This requirement is not met as evidenced by:
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In-service training for all medication technicians shall be completed on documentation of medications. Training materials and rooster of staff attendances shall be submitted to the department by POC due date 04/05/24.
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Based on observation, the licensee did not comply with the section cited above when resident’s medication and MARs was reviewed and observed medications were not logged into residents’ Centrally store medication log, which poses a potential health, safety or personal rights risk to person 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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2