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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:26:03 PM

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
01/12/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230112171155
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: 21DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Sandra GuadarramaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff are providing would care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the 10-Day complaint investigation. LPA met with and reviewed allegation with Care Coordinator (S1) Sandra Guadarrama.

During the visit, LPA observed Residents R1, R2 and R3 in their rooms, interviewed staff and conducted record review of R1, R2 and R3’s facility file. S1 provided a copy of requested documents.

Based on interviews, unlicensed staff are providing wound care to residents R1, R2 and R3. Staff (S1) stated that there is no documentation of the trainings which have been provided by a licensed professional for each resident. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

See LIC9099-C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 3
Control Number 24-AS-20230112171155
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: 01/19/2023
NARRATIVE
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An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were left with Sandra Guadarrama, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230112171155
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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited
CCR
87613(a)(2)
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87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. This requirement was not met as evidenced by:
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Facility has agreed to provide proof of training by a licensed professional to staff that assist with residents individualized specialized care needs.
Proof of training will be provided which includes each resident's care instructions, name/title of trainer, date(s) of hands on training. A sign in sheet to include the
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Licensee did not ensure that staff members who participate in wound care of R1, R2 and R3 have documentation of training provided by a licensed professional based on physician order. There are no written instructions for staff to follow or documentation of hands on instruction given by the facility or Home Health Nurses.

This provides a potential health, safety or personal rights risk to residents in care.
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 signature of each trained staff will be provided to CCLD by the POC date.

Additionally, facility agrees to maintain a copy of the care instructions in the residents room and file for reference. Training will be updated if residents care needs change based on physician orders.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3