<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 05/26/2021
Date Signed: 05/26/2021 01:48:55 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2020 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20200811145703
FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:PARKKILA, PAMELAFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Michael Chapman, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing care and supervision to meet resident's needs.
Facility mismanaged resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/26/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegations.

The Department investigated the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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 2
Control Number 24-AS-20200811145703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2021
Section Cited
HSC
1569.312(a)
1
2
3
4
5
6
7
ยง1569.312Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director of Resident Services conducted an in-service training regarding the management of Oxygen. Regulation 87618 has been added the Restricted/Prohibited Health Care plan binder located in the wellness office. *Plan of correction/ Deficiency cleared*
8
9
10
11
12
13
14
Interviews and records review stating R1's oxygen tank was empty due to a hole in the tubing. No refill was ordered or available as needed under Basic care needs. This poses an immediate health and safety risk to those in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2