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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206604
Report Date: 10/25/2021
Date Signed: 10/26/2021 09:34:54 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
07/28/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210728160819
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:
10/25/2021
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Administrator Arnulfo GonzalezTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff did not ensure that resident had a sufficient amount of liquids
Facility staff did not ensure that resident had a sufficient amount of food
Facility staff did not safeguard resident's property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA explained the purpose of the visit was to deliver findings to Administrator Arnulfo Gonzalez.

After reivew of medical records and interviews it was undetermined whether or not the facility provided a sufficient amount of liquids and food.
After review of records and interviewed it was undetermined whether or not the facility safeguarded the residents property.

Although the allegations Facility staff did not ensure that resident had a sufficient amount of liquids,
Facility staff did not ensure that resident had a sufficient amount of food, Facility staff did not safeguard resident's property may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Arnulfo Gonzalez and a copy of this report was provided to Administrator Arnulfo Gonzalez via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 4
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
07/28/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210728160819

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:
10/25/2021
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Administrator Arnulfo GonzalezTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility staff did not allow resident to have visitors
Facility staff did not provide resident's representative with a copy of the resident's records
Resident did not have a signed admissions agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA explained the purpose of the visit was to deliver findings to Administrator Arnulfo Gonzalez.

LPA reviewed records and the care plan stated allow visits once R1 has bonded with facility staff.
LPA reviewed records and conducted interviews. LPA observed a request was sent certified mail requesting R1's records on 10/5/21.
LPA reviewed resident records, which has an unsigned admissions agreement for R1.

Based on LPA interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Arnulfo Gonzalez and a copy of this report was provided to Administrator Arnulfo Gonzalez via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 4
Control Number 24-AS-20210728160819
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2021
Section Cited
HSC
1569.313
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Residential care facilities for the elderly; family visits and communication policy; statement on client information or admission agreement form and patient's rights form Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient's rights form, the facility's policy concerning family visits and other communication with resident clients and
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Plan of Correction POC Licensee agrees to provide a written understanding of this regulation and submit by POC due date 10/29/21
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shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility's policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. Based on interviews and records review, Licensee did not allow family to visit R1 which poses an immediate health and safety risk to residents in care.
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Type B
10/29/2021
Section Cited
CCR
87506(c)(1)
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87506 Resident Records
(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees
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Plan of Correction POC Licensee agrees to provide a written understanding of this regulation and submit by POC due date 10/29/21
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 shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews and certified mail request sent on 10/5/21 Licensee did not provide a copy of resident records to responsible party which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20210728160819
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
87507(c)
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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
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Plan of Correction POC Licensee will submit a written understanding of this regulation by POC due date 10/29/21
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This requirement was not met evidenced by: Based on records review and interviews Licensee did have a signed admissions agreement for R1 a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4