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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:32:13 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:
547209193
ADMINISTRATOR:GIBSON, ERNESTFACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVETELEPHONE:
(650) 580-5475
CITY:VISALIASTATE: CAZIP CODE:
93710
CAPACITY:59CENSUS: 16DATE:
11/08/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Applicant Representative Mark Peper and Administrator Ernest GibsonTIME COMPLETED:
05:00 PM
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On 11/06/21 at 11:00 AM Licensing Program Analyst (LPA) Shawna Doucette arrived to the facility announced to conduct the Pre licensing visit. LPA Shawna Doucette met with Applicant Representative Mark Peper and Administrator Ernest Gibson. LPA Shawna Doucette, Program Manager Sergiy Pidgirny and Investigator Elisia Rippe toured the facility.

Common rooms have adequate furnishings and lighting. All of the resident bedrooms have all the required furnishings and adequate lighting. Hot water temperature in bathrooms measured at 111.1 degrees F on assisted living side and 105 degrees F on memory care side. LPA observed a supply of extra bed linens. Kitchen observed to have dishes, plates, utensils. Cleaning supplies are stored in a locked closet. Medications are locked in a medication closet. First aid kit contains all the required items. A fire extinguisher is present and has a service date of 7/11/2021. Smoke detectors and carbon monoxide were operating. Facility has pull station alarm.

Outside of the facility toured. Exits open free of obstruction. The residence has a delay egress which sounds the indoor alarm. No outside hazards were observed. No pools or bodies of water.

All required postings are posted. Facility phone number will be (559) 625-6001.

Component III was conducted at the Regional Office with Applicants.

I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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