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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206604
Report Date: 07/06/2020
Date Signed: 07/06/2020 03:12:25 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
03/16/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20200316121132
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: 25DATE:
07/06/2020
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Licensee Esperanza HansenTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Unqualified staff is providing care and supervision
Facility has inadequate record keeping
INVESTIGATION FINDINGS:
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Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this investigation by phone and correspondence.

On this date Licensing Program Analyst (LPA) K. Mcclurg conducted a telephone interview with Licensee Esperanza Hansen. LPA notified Administrator that the purpose of this call was regarding a Complaint investigation.

The Department conducted staff & record reviews.

Continued.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020
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-20200316121132
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 PARK ASSISTED LIVING
FACILITY NUMBER: 547206604
VISIT DATE: 07/06/2020
NARRATIVE
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Continued from page 1

Facility staff & physician interviewed & records reviewed. California Board of Registered Nursing show Licensee's license as a Registered Nurse (RN) in California is current & in good standing. Medication training is overseen by RN & medication is dispensed by staff that have completed medication training & dispensed in accordance with physician's orders. Physician verified orders issued & physician reports were reviewed & completed by physician. Physician is on facility premise's twice a month or more as needed.

The Department has investigated the above allegations. The Department has found the allegations were unfounded.

Exit interview conducted with Licensee Esperanza Hansen.

Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2