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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 07/26/2024
Date Signed: 07/26/2024 06:41:14 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
07/23/2024 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20240723141849
FACILITY NAME:MAGNOLIA PARK ASSISTED LIVINGFACILITY NUMBER:
547209193
ADMINISTRATOR:RAMOS, MESHELLFACILITY TYPE:
740
ADDRESS:2950 E. DOUGLAS AVETELEPHONE:
(559) 625-6001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:59CENSUS: 25DATE:
07/26/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director/Administrator (Admin) Meshell (Shelly) RamosTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility did not refund money
INVESTIGATION FINDINGS:
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A An unannounced Complaint visit was conducted by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Executive Director/Administrator (Admin) Meshell (Shelly) Ramos. LPA greeted Admin, stated purpose of visit, & was allowed to proceed.

Issue was reviewed with Admin. It was determined that Resident 1 (R1) died on May 5, 2024. Facility had been paid in full for the month of May 1, 2024 through May 31, 2024. R1 passed away May 5, 2024. The facility has not issued a refund for the prorated amount from May 6, 2024 through May 31, 2024.

Deficiency Issued.
Exit interview conducted with Admin. Report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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 2
Control Number 24-AS-20240723141849
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: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87507(g)(5)(A)
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Admission Agreements. Facility policy concerning refunds, including…a refund for advanced monthly fees will be returned in the event of a resident’s death…Payment for R1 in the
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Facility to issue refund in the amount of $2623.74 immediately. The following must be sent to the Department prior to end of business day on Tuesday, July 30, 2024:
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amount of $3486.00 was paid in full for the month of May 2024. Facility accepted & processed payment. R1 died 5/4/24. To date, the facility has not issued refund for the prorated amount due of $2623.74 for the 26 remaining days after death from 5/6/24 to 5/31/24.
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 1.) Copy of Refund check; 2.) Copy of proof that sent by Certified Mail. Submit by email to LPA by due date before the end of the business day.
Failure to correct citation on time may result in additional citations &/or in civil penalties.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
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