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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 03/22/2023
Date Signed: 03/23/2023 10:25:48 AM

Substantiated


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
08/02/2022 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220802132508
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: 22DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Resident Care Director, Sandra GuadarramaTIME COMPLETED:
02:32 PM
ALLEGATION(S):
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Staff lacks qualifications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA Williams met with Resident Care Director Sandra Guadarrama (RC) and discussed the purpose of the visit. RC contacted the Administrator and notified of the LPA's visit.

LPA Williams toured the facility with RC and reviewed 5 employee files.

Three employees had last documented training during the months of January and February 2022. No updated annual training records were located. Staff 1 verified their record was accurate and that they last completed training in January and February 2022 and no annual training had been completed since.

*Continued on LIC-9099C*

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 24-AS-20220802132508
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: 03/22/2023
NARRATIVE
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Staff 2's 1st AID/AED/CPR expired January 2023. LPA Williams did not locate an updated record.

Staff 4 did not have 1st AID/AED/CPR in the their file. S4 reported they did not have a copy to show LPA Williams and they have not provided a copy to the Licensee. S4 was unsure of the date they completed training, but believed it may have been a year ago.

Based on the LPA's interview and record review, the preponderance of evidence standard has been met, therefore the allegation, staff lack qualifications is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8, Article 7, Section 87411(c), is being cited on the attached LIC 9099-D page.

LPA Williams discussed Plan of Correction with RC.

An exit interview was conducted and a copy of this report and Appeal Rights will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20220802132508
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited
CCR
87411(c)
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87411 - Personnel requirement General;
(c) - All RCFE staff who assist residents ... initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement was not met evident by:
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The Resident Care Director, agreed to provide updated annual training records for 5 identified staff to the Department by POC due date of 4/3/2023.
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Based on staff record review, the Licensee did not ensure staff completed annual training, which poses a potential health and safety risk to person's in care.
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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: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/02/2022 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220802132508

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: 21DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Resident Care Director, Sandra GuadarramaTIME COMPLETED:
02:32 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility is not following reporting requirements.
Facility restrained residents.
Resident was made to wait to use the restroom for an excessive amount of time.
Uncleared adults working at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA Williams met with Resident Care Director Sandra Guadarrama (RC) and discussed the purpose of the visit. RC contacted the Administrator and notified of the LPA's visit.

LPA Williams toured the facility and conducted interviews.

In regards to the allegation facility is not following reporting requirements. LPA Williams interviewed staff who reported when an unusual incident occurs, they contact authorized representative, medical services (if needed), and Community Care Licensing. LPA Williams reviewed the Departments digital folder, and observed incident reports provided to the Department from the facility.

*Continued on LIC 9099-C*
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20220802132508
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: 03/22/2023
NARRATIVE
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In regards to the allegation, facility restrained resident, LPA Williams observed three residents in the dining room, in wheel chairs, with nothing mechanical restraining their mobility. LPA Williams residents in their rooms, either on the bed or chairs. Once again, LPA Williams did not observe anything mechanical restraining their mobility.

In regards to the allegation, resident was made to wait to use the restroom for an excessive amount of time, Staff 6 was no longer employed and Resident 1 moved out. LPA Williams could not interview to clarify statements.

in regards to the allegation, uncleared adults working at the facility, Staff reported Subject 1 was not employed by the facility and only saw them come by to drop off food to another staff member. LPA Williams conducted a back clearance check via, Licensed Information System, and all staff currently on shift had a valid criminal clearance.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5