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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 02/13/2023
Date Signed: 02/13/2023 08:48:54 PM


Document Has Been Signed on 02/13/2023 08:48 PM - 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:X,XFACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVETELEPHONE:
(559) 625-6001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:59CENSUS: 23DATE:
02/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Administrator- Shelly RamosTIME COMPLETED:
02:10 PM
NARRATIVE
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On 2/13/23 at 9:50 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA was greeted by S1 and allowed entry into the facility. S2, S4, and Administrator Shelly Ramos arrived later.

From the outside of the entrance LPA observed resident R1 going in and out of the kitchen and setting the tables. Later S2 explained R1 likes to help out when they are agitated or bored. LPA waited for the door to be answered. LPA observed one staff member for 13 residents in House B for Assisted Living. LPA toured the facility and found the kitchen to be unlocked with sharps accessible to the residents. S1 stated the kitchen is normally locked but S1 was doing dishes. Later when LPA asked S2 about the kitchen being unlocked, S2 stated the kitchen is always unlocked. LPA explained to S2 that LPA observed kitchen with the two left stove burners were left on low, knives were accessible to residents in unlocked drawers, coffee pot was on, and scissors were accessible to residents on the counter. LPA also heard a resident crying for help. Staff had to leave LPA to help resident and was not be able to conduct the tour at that time. LPA asked how many staff are currently at the facility, S1 stated one staff member in House A and one staff member in House B. Later S2 explained this was an unusual event because there was a miscommunication with schedule and S2 was supposed to be at the facility.

LPA toured House A which has 10 residents and 1 staff member. LPA reviewed current LIC9020, 2 of the 10 residents are ambulatory, 8 of the 10 residents are non-ambulatory. LPA asked S3 what the protocol is if one resident needs to be changed and a high risk fall resident is trying to get up, S3 stated they were not sure. S3 also stated they are a new employee to the facility.
Exit interview was conducted, a copy of LIC809 and LIC809Ds were provided to Administrator Shelly Ramos.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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 3


Document Has Been Signed on 02/13/2023 08:48 PM - 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: 02/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2023
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Kitchen will remain locked and inaccessible to residents. Notice will be place in communication log to all staff, and issue will be addressed at all staff meeting. Verification will be sent to LPA by 2/27/2023
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen stove on, knives and scissors unlocked and accessible to residents.
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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: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/13/2023 08:48 PM - 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: 02/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

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Facility will have a contingency plan in order when staff is short, or miscommunication with scheduling. Verification of plan will be sent to LPA.
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This requirement is not met as evidenced by:
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. LPA observed facility without adequate staff upon arrival to the facility.
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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: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3