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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206604
Report Date: 10/27/2021
Date Signed: 10/28/2021 08:26:06 AM

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:
10/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Licensee Esperanza HansenTIME COMPLETED:
06:30 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 was met at the entrance by Staff Eehai See. LPA toured the facility with Licensee Esperanza Hansen. LPA observed both assisted living and memory care.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors.

Upon entry residents were observed to have just finished dinner, which was french dip sandwich, mushroom soup, salad and watermelon. Residents were interacting with each other in the dining area and some residents were in their room.

LPA observed Residents on the memory care side to be sleeping in their rooms or getting ready for bed.

LPA observed a two supply of perishable and a 7 day supply of nonperishable food.

LPA Shawna Doucette requested the facility's resident roster to be emailed.

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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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