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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 09/13/2022
Date Signed: 09/13/2022 11:21:17 AM


Document Has Been Signed on 09/13/2022 11:21 AM - It Cannot Be Edited

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, ERNEST G.FACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVETELEPHONE:
(559) 625-6001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:59CENSUS: 23DATE:
09/13/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Meshell "Shelly" RamosTIME COMPLETED:
11:40 AM
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On 9/13/22 at 9:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a POC inspection. LPA was greeted by staff and granted entry. Executive Director (ED) Meshell "Shelly" Ramos arrived approximately 50 minutes later.

On 9/1/22, LPA issued a deficiency in violation of CCR 87211(a)(1) with a Plan of Correction to be due by 9/2/22. The Plan of Correction was reviewed and developed with ED. As of today, 9/13/22, CCL has not received the submission of the POC. ED could not produce proof that the POC was sent.

A civil penalty is being assessed for failure to correct CCR 87211(a)(1) for the period of 9/3/22 through 9/13/22 (11 days) in the amount of $100 per day per citation, for a total of $1100. A civil penalty of $100 per day per citation will continue until deficiency is corrected. See form LIC421FC for more detail.

Exit interview was conducted. A copy of this report and appeal rights were given to Executive Director Meshell "Shelly" Ramos, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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