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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206604
Report Date: 10/15/2021
Date Signed: 10/15/2021 06:05:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MAGNOLIA PARK ASSISTED LIVINGFACILITY NUMBER:
547206604
ADMINISTRATOR:GONZALEZ, ARNULFOFACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVE.TELEPHONE:
(559) 625-6001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:59CENSUS: 19DATE:
10/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:14 PM
MET WITH:Licensee Esperanza HansenTIME COMPLETED:
06:00 PM
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Licensing Program Analyst Shawna Doucette arrived at the facility unannounced to conduct a Case Management Inspection for a health and safety check. LPA toured the facility both assisted living and memory care.

LPA observed a two supply of perishable and a 7 day supply of nonperishable food. LPA entered the facility and observed all residents in the dining area having dinner.

An exit interview was conducted with Licensee Esperanza Hansen and a copy of this report was provided via email.


SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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