<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206604
Report Date: 11/02/2021
Date Signed: 11/03/2021 01:37:17 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: 18DATE:
11/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Licensee Esperanza HansenTIME COMPLETED:
07:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 Eehai See. LPA toured the facility with Licensee Esperanza Hansen. LPA observed both assisted living and memory care. LPA counted 9 residents in assisted living and 9 residents in the 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 be in their rooms. LPA observed dinner to be chicken soup, 1/2 sandwich and fruit.

LPA observed Residents on the memory care side to be sleeping in their rooms or interacting with staff. Licensee stated one resident is at an appointment.

LPA observed a two supply of perishable and a 7 day supply of nonperishable food. LPA observed large cans of various fruits and vegetables. LPA observed cans of various soups. LPA observed large containers and bags of rice and beans. LPA observed various large cans of sauces. LPA observed oatmeal and cream of wheat. LPA observed canned chicken, pork and tuna. LPA observed pasta and corn meal. LPA observed a walk in fridge and freezer containing milk, fresh vegetables, eggs, fresh fruits, tortillas, bread, cheese, butter. LPA observed a walk in freezer full of various meats. Facility has water, gas and electric. LPA obtained a copy of the resident roster.

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: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1