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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 03:16:37 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
02/14/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20200214120451
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: DATE:
07/06/2020
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Licensee Esperanza HansenTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Licensee did not refund responsible party after resident passed away and resident's belongings were removed.
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.
Unsubstantiated
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-20200214120451
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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Complainant withdrew allegation.

The Department has investigated the above allegation. The Department has found the allegation was unsubstantiated.

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