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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 11/29/2022
Date Signed: 12/08/2022 08:09:09 AM


Document Has Been Signed on 12/08/2022 08:09 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
SIERRA CASCADE AC/SC, 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: 24DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Meshell Ramos & Health Services Director Norma PedrozaTIME COMPLETED:
01:45 PM
NARRATIVE
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On 11/29/2022 at 9:50 a.m. Licensing Program Analyst (LPA) B. Miranda conducted an unannounced Annual Inspection visit LPA was Covid screened at the lobby area. LPA was met by Health Service Director Norma Pedroza. Norma attempted to get a hold of Administrator (AD) Meshell Ramos. Contact was made with Meshell Ramos and stated she would be arriving at the facility.

The facility consists of assisted living and memory care residents and a tour was conducted. LPA observed fire extinguishers were up to date on service and in good standing. Fire company Security First is currently on site working on the fire alarms due to being activated when heater is turned on.

LPA did not observe any obstruction or clutter throughout the facility. LPA did observe two bathrooms in house B unlocked with cleaning supplies/aerosols accessible to the residents, this is a deficiency.

In house B water temperature was check in a residents room which read at 126.3 degrees Fahrenheit, which is a deficiency. Resident water temperature was checked in house A (memory care) where residents use the bathroom and bathe, temperature read at 106.3 degrees Fahrenheit. Water was also checked in the kitchen (house A) where residents do not have access and temperature read at 141 degrees Fahrenheit which will need a warning sign, AD was informed.

LPA observed a few small signs for washing hands and infection control. AD was informed there should also be signs for "See Something, Say Something".

Main kitchen is located in house A, has self locking door, and is not accessible to residents, there is 2 days worth of perishable food and 7 days worth of non-perishable foods. Cooking staff stated food orders are placed on Tuesdays and delivered on Wednesday every week.

While walking from house B to house A it was noticed one of the emergency exits might have a broken handle, AD was informed the handle/lock would need to be repaired.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MAGNOLIA PARK ASSISTED LIVING
FACILITY NUMBER: 547209193
VISIT DATE: 11/29/2022
NARRATIVE
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Medications in both houses are locked and inaccessible to residents. Both houses have a 30-day supply for residents.
LPA observed first aid kit and there a multiple aid kits in the facility.

Two staff member's files were reviewed. LPA observed certificates in files to verify training.
Two resident profiles were reviewed. LPA observed admission agreements, resident appraisals, and emergency contact information.

Exit interview completed with AD.
Copies of 809, 809C, and 809D provided to AD with appeal rights.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/08/2022 08:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAGNOLIA PARK ASSISTED LIVING
FACILITY NUMBER: 547209193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above, which poses an immediate
health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2022
Plan of Correction
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All cleaning products will be kept in locked storage an inaccessible to residents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/08/2022 08:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAGNOLIA PARK ASSISTED LIVING
FACILITY NUMBER: 547209193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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Water heater temperature will be reduced to be incompliance. Administrator will provide pictures verifying temperature is in compliance or paper work from a service company.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4