547209193-1-13-2023-24-AS-SPIY-CN9LU8-20230120080330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 01/12/2023
Date Signed: 01/13/2023 11:08:09 AM

Unsubstantiated

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
01/09/2023 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230109144517

FACILITY NAME:	MAGNOLIA PARK ASSISTED LIVING		FACILITY NUMBER:	547209193
ADMINISTRATOR:	X,X		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	59	CENSUS: 20	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	04:40 PM
MET WITH:	Administrator, Shelly Ramos		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff are not preventing resident from assaulting other residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit and health and safety check. LPA Williams met with Administrator, Shelly Ramos and discussed the purpose of the visit.

LPA Williams toured the facility and observed 6 residents in the living room and 2 residents in their bedrooms. LPA Williams attempted to interview residents with no success. LPA Williams did not observe any visible marks on residents.

LPA Williams interviewed Staff 1, Staff 2, and Administrator, and who all reported they have not witnessed or heard of any residents assaulting another resident.

*Continued on LIC 9099C*

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20230109144517

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
	VISIT DATE: 01/12/2023

NARRATIVE

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Regarding the allegation, there is no victim or suspected abuser identified. Additionally, there is no contact info for the reporting party to clarify any statement.

Based on the LPA's observation and interviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report will be provided via e-mail.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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