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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 11/05/2021
Date Signed: 11/07/2021 09:18:52 AM



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
10/28/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211028110923
FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:CHAPMAN, MICHAELFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: 92DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Executive Director, Michael ChapmanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Visitors were not wearing masks.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/05/21, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required 10 day site inspection. LPA was greeted by Executive Director, stated purpose of visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of LPA's entry.

During the course of the investigation, LPA toured the facility inside and out. During the tour, LPA observed all staff members wearing masks. Residents were observed social distancing in the dining area.

Based on LPA's observation, there was not an evidence to support this allegation that occurred the year prior. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit Interview conducted. No deficiency issued on today's vist.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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
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
10/28/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211028110923

FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:CHAPMAN, MICHAELFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Executive Director, Michael ChapmanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not inform responsible party that resident had tested positive for COVID-19.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/05/21, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required 10 day site inspection. LPA was greeted by Executive Director(ED), stated the purpose of visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of LPA's entry.

LPA reviewed hospital medical records, facility's COVID positive records that were reported to Kern County Public Health in 2020. LPA reviewed documentation of a negative COVID test result for Resident R1 dated 12/23/20. LPA also conducted interview with Executive Director.

Based on records review and interview, Resident R1 was COVID tested at the hospital December 27, 2020. Records review reveal R1 never returned to the facility after testing positive for COVID and was sent to Skilled Nursing for a higher level of care after R1 was discharged. When R1 left the facility to the hospital, R1 did not return, the hospital did not report the COVID positive to the facility. Facility was informed by family that R1 was COVID positive, R1 was no longer in facility's care at that time.

Based on the information received, the Department has found that the complaint is UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2