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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 02/13/2023
Date Signed: 02/28/2023 02:41:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
11/21/2022 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221121144407
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: 23DATE:
02/13/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Angelica Pimental Admin Support & Sandra Guadarrama Resident Care Director/Lead Med TechTIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff's conduct poses a risk to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/13/23 at 9:50 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver finding for the allegations listed above. LPA was greeted by S1 and allowed entry into the facility. Administrator Shelly Ramos was contacted and gave authorization for S1 or S2 to signed the report.
1. The Department investigated the allegation: Staff's conduct poses a risk to residents in care. LPA conducted multiple interviews and reviewed records.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted. A copy of this report was provided to S2 & S4.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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