547209193-8-12-2022-24-AS-SPIY-CL7MVH-20221115085646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:56:25 PM

Substantiated

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
08/05/2022 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20220805141254

FACILITY NAME:	MAGNOLIA PARK ASSISTED LIVING		FACILITY NUMBER:	547209193
ADMINISTRATOR:	GIBSON, ERNEST G.		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	59	CENSUS: 19	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Staff Meshell Ramos		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility administrator is not present at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Doucette and LPA Brianna Miranda contacted the facility to commence a complaint investigation. LPA identified themselves and discussed the purpose of the visit and the elements of the allegations with Staff Meshell Ramos. LPA asked if the Administrator was available to respond to the facility for the visit. Staff Meshell Ramos stated the Administrator is not available.

LPA was at the facility on 8/4/22 and requested the documentation for the current Administrator of the facility. LPA requested the documentation by 8/5/22 at 5 PM. LPA has not recieved copies of the Administrator documents. The staff file for the Administrator is not available at the facility for LPA to view.

Based on records review and observation there is not an Administrator at the facility, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87405(a) is being cited on the attached LIC 9099D.
An exit interview was conducted, a copy of this report was provided, and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20220805141254

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: 547209193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/12/2022 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.	1 2 3 4 5 6 7	Plan of Correction POC During the visit, documentation was submitted for an Administrator via email. POC cleared during visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: The Licensee does not have an Administrator on file for the facility or a staff file at the facility for an Administrator which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

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