<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:30:03 AM


Document Has Been Signed on 02/02/2023 11:30 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:X,XFACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVETELEPHONE:
(559) 625-6001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:59CENSUS: 22DATE:
02/02/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mark Peper Appointed Conservator (AC); Shelly Ramos Executive Director (ED);TIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An Informal Meeting was conducted at the Fresno Regional Office on this date. Present during the meeting were:

Brenda White, Regional Manager
See Moua, Licensing Program Manager
Kelly McClurg, Licensing Program Analyst

Mark Peper, Licensee Representative.
Shelly Ramos, Executive Director

The purpose of the meeting was to discuss the following concerns regarding the facility –
· The number of complaints the facility has received
· Verification of Facility’s Administrator and Administrator’s Qualifications, Duties, and Responsibilities
· Staffing Schedule
· Staff and Residents’ files

The facility agreed to submit the following to the Fresno office by due date identified below:
  • Completed Facility Staff Roster (LIC 500);
  • Updated Lease Agreement;
  • Updated completed Administrator Documents
Due Date for above documents: FRIDAY, FEBRUARY 10, 2023
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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 1