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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206604
Report Date: NO Visit Data Available
Date Signed: 09/13/2021 06:11:15 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
08/31/2021 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20210831120833
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:
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Licensee Esperanza Hansen & Supervisor Eehai See & Administrator Arnold Gonzalez;TIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did provide resident's medications when resident moved from facility
Facility did not refund resident's money after resident moved from facility
INVESTIGATION FINDINGS:
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A Complaint visit was conducted by Licensing Program Analyst (LPA) K. McClurg. LPA met with Licensee (L) Esperanza Hansen & Supervisor(S) Eehai See & Administrator (Admin) Arnold Gonzalez. LPA reviewed allegations with L, S, Admin.

Records for Resident 1 (R1) reviewed. Interviews conducted. Medication Release form dated 8/25/21 with medication count has Power of Attorney (POA) signature for medication as received dated 8/25/21 & signed same date by S.

Admission agreement dated at time of move-in & signed by POA states that "Thirty day written notice to move from facility is required. Any basic rate paid for the thirty days after the date the written notice is given will not be refunded." Pro-rated refund dated 9/3/21 issued.

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: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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 2
Control Number 24-AS-20210831120833
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: 09/13/2021
NARRATIVE
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Continued from page 1.

The Department has investigated the above allegations & determined them to be unfounded.

No deficiencies issued. Exit interview conducted with L & Admin. Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2