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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 09/26/2022
Date Signed: 09/26/2022 11:54:31 AM


Document Has Been Signed on 09/26/2022 11:54 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: DATE:
09/26/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Meshell "Shelly" Ramos, Executive DirectorTIME COMPLETED:
12:30 PM
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On 9/26/22 at 11:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a Plan of Correction inspection. LPA explained reason for inspection and was granted entry by staff. LPA met with Executive Director (ED) Meshell “Shelly” Ramos, who arrived about 30 minutes later.

On 9/13/22, LPA assessed a civil penalty for failure to correct deficiency in violation of CCR 87211 (a)(1) issued on 9/1/22. LPA advised verbally and in that day’s report that additional civil penalties would be assessed if the POC was not submitted by the end of the day to CCL. LPA confirmed with ED that the facility did not have an issue with their fax machine. LPA advised an email submission of the POC was acceptable. CCL did not receive the POC via fax transmission, mail, or drop off. On 9/19/22, LPA received the POC via email from S1. LPA confirmed with ED that S1 submitted the POC on behalf of the facility.

A civil penalty will be assessed as continuation of a daily penalty that was first assessed on 9/13/22 for CCR 87211(a)(1), with continuation starting from 9/14/22 through 9/19/22, in the amount of $100 per continuation day, for a total of $600. See form LIC421FC for more details.

Exit interview conducted. A copy of this report and appeal rights were given to Executive Director Meshell 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: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
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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