547206604-10-26-2021-24-AS-SPIY-C8DMRL-20211102095031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547206604
Report Date: 09/28/2021
Date Signed: 10/26/2021 12:29:23 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
08/18/2021 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210818154401

FACILITY NAME:	MAGNOLIA PARK ASSISTED LIVING		FACILITY NUMBER:	547206604
ADMINISTRATOR:	GONZALEZ, ARNULFO		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE.		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	59	CENSUS: 19	DATE:	09/28/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Esperanza Hansen		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff denied residents authorized representative of medical documents

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED REPORT
Licensing Program Analyst (LPA) Katie Brown arrived to the facility unannounced to deliver the investigation findings. LPA met with

The Department has investigated the complaint alleging: Staff denied residents authorized representative of medical documents. Based on interview conducted with Reporting Party (RP) a letter requesting documents was sent via email to Administrator. Per RP, not all of the documents requested were provided by the facility. Based on interviews conducted and records review of the emails and text messages, the department is unable to determine if the facility received the original email containing the entire list of requested documents from R1’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

No deficiencies cited on today's visit

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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