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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 03/11/2024
Date Signed: 04/02/2024 02:23:23 PM


Document Has Been Signed on 04/02/2024 02:23 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:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator Paul Anderson, Licensed Vocation Nurse Palvire Bassia, and Director of Residential Services Shellie WhitlockTIME COMPLETED:
06:00 PM
NARRATIVE
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On 03/11/24, Licensing Program Analysts (LPA) M. Yang and K. Kaur arrived at the facility unannounced to conduct the Annual Inspection. LPA met Administrator (A1) Paul Anderson, Licensed Vocation Nurse (LVN) Palvire Bassia, and Director of Residential Services (DRS) Shellie Whitlock. LPAs conducted tour of facility with A1, LVN, and DRS.

Facility consists of Assisted Living (AL) and Memory Care (MC) Unit. LPAs toured a sample of resident bedrooms in Assisted Living and Memory Care. Residents were observed seating in common areas. Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 09/09/2023. LPAs toured kitchen. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. LPA observed janitor cart and cleaning chemicals stored unlock in janitor and mechanical room. LPA observed medications and cleaning chemicals unlock in residents’ room. Bathrooms hot water temperature was tested and within range between 113.7 to 118.2. LPA observed securely fastened grab bars and non-skid surfaces/mat in shower. Bathrooms was observed operational. LPA observed a hole in under resident’s kitchen sink. LPAs observed exits in Memory Care to have a 30-second delay egress. The outside was toured and observed to be free from debris with outdoor seating available for residents. A sample of resident and staff files were reviewed to have all the required documents. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22,Division 6. Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 03/18/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E. A copy of this report and appeal rights was provided to Administrator.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2024 02:23 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPAs and A1 observed cleaning
chemicals in janitor and mechanical rooms unlocked. LPA and A1 observed chemical bottles and a knife in room 123, and
chemical bottles in room 103 stored unlocked accessible to residents in care this poses an immediate health, safety or
personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator immediately locked janitor and mechanical room. Chemical bottles and knife were immediately removed from
the residents’ room to locked area by Administrator. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed medications in
room 130 and 103 stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights
risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Administrator immediately removed medications to locked area. POC cleared during visit.
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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/02/2024 02:23 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance
services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed a square hole in
the back wall under R1’s kitchen sink. Under ice machine in the kitchen LPAs and A1 observed mold, which poses a
potential health, safety or personal rights risk to person in care.
POC Due Date: 04/03/2024
Plan of Correction
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Ice machine was cleaned immediately. Wall under kitchen sink in R1’s room shall be repair and proof of repaired shall be
submitted to the department by POC due date 4/3/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3