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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 03/19/2024
Date Signed: 03/22/2024 03:03:09 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
02/20/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240220184101
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
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff are not dispensing medications to the residents as prescribed
INVESTIGATION FINDINGS:
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On 03/19/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock

During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. Based on records reviewed and observation medications were not administered as instructed by doctor's order. Based on records reviewed and observation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this report confirms 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20240220184101
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87465(a)(5)
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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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Plan of correction of action plan the facility will take to ensure regulations is met at all times shall be submitted to CCL. POC of action plan will be submitted to department by 03/20/24.

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Based on interviews and records review, the licensee did not ensure staff administer medications residents as prescribed by physicians, which poses an immediate health and safety risks to persons in care.
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All medication technician staffs shall be retrained on administering medication. Copies of trainings and rooster of all staff attendance will be submitted to department by 04/05/24.
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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
LIC9099 (FAS) - (06/04)
Page: 2 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
02/20/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240220184101

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
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie WhitlockTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is unclean, smell, unsanitary, and have pests
Facility staff failed to meet resident’s hygiene needs
Facility staff are not meeting resident’s needs
Facility staff are not answering the resident’s call assistance in a timely manner
Facility staff are not maintaining proper documentation on residents
Facility staff are not adequately trained

INVESTIGATION FINDINGS:
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On 03/19/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock

During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. Interviews conducted the facility has ants with pest control services in place. Facility records were reviewed, the facility is maintaining pest control service monthly for ants and interior insects. LPA toured the facility; the facility was observed with no smell and is sanitary. The facility elevator was observed cleaned and records were reviewed with facility infection control plan in place. Allegations that the facility is unclean, smell, unsanitary and have pest are found to be UNSUBSTANTIATED, the preponderance of evidence standard has not been met and due to facility seeking assistance from pest control to eradicate the ants and bedbugs.

continue...
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: 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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240220184101
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: 03/19/2024
NARRATIVE
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continue...

Based on interviews conducted and records reviewed, the residents receive showers by staff weekly, therefore, allegation facility staff failed to meet resident’s hygiene needs is found to be UNSUBSTANTIATED.

Based on interviews conducted and records reviewed, staff response to residents needs in a timely matter and assist residents with their needs as requested. The allegation facility staff are not answering the resident’s call assistance in a timely manner and staff not meeting resident’s needs; the preponderance of evidence standard has not been met, the allegations are found to be UNSUBSTANTIATED.
Based on records reviewed, incidents that occurred are documented on resident’s progress notes. Therefore, the preponderance of evidence standard has not been met, the allegation facility staff are not maintaining proper documentation on residents is found to be UNSUBSTANTIATED.
An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this report confirms receipt of this report.

Based on interviews conducted and records reviewed, staff response to residents needs in a timely matter. The allegation facility staff are not answering the resident’s call assistance in a timely manner; therefore, the preponderance of evidence standard has not been met, the allegation found to be UNSUBSTANTIATED.
Based on records reviewed, incidents that occurred are documented on resident’s progress notes. Therefore, the preponderance of evidence standard has not been met, the allegation facility staff are not maintaining proper documentation on residents is found to be UNSUBSTANTIATED.

Based on records reviewed, all medication technician have up to date medication training, therefore the allegation facility staff are not adequately trained is found to be UNSUBSTANTIATED.

An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this report 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4