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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:09:02 PM

Unsubstantiated


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
02/16/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20230216124448
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: 31DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director (ED) Shelly Ramon; Resident Care Director (RCD) Sandra Guadarrama; TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staffing to ensure that residents receive proper care
Staff are not adequately trained
Staff do not have PPE while caring for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint visit was conducted on the date & times indicated above by Licensing Program Manager (LPM) See Moua & Licensing Program Analyst (LPA) Kelly McClurg.

The Department conducted a tour of the facility, reviewed records, and conducted interviews. Three caregivers were observed on duty, along with the LVN, Resident Care Coordinator, and a lead and assistant cooks. Administrator was also present during the inspection. Resident’s call pendants were checked and staff assisted in a timely manner. A sample of staff’s training records were checked and reviewed and staff had required training. PPE were checked and observed. Based on observations and records reviewed, the above allegations are Unsubstantiated. Exit interview was conducted.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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 2
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
02/16/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20230216124448

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: 31DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director (ED) Shelly Ramon; Resident Care Director (RCD) Sandra Guadarrama; TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Ombudsman signage is not posted in the facility;
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted a tour of the facility. Ombudsman posters were observed in the common areas of both buildings of the facility. The allegation is Unfounded. Exit interview was conducted.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2