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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 06/29/2023
Date Signed: 06/30/2023 03:52:55 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
03/20/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20230320091521
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
Resident developed multiple pressure injuries while in care;
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. LPM & LPA met with Executive Director (ED) Shelly Ramon & Resident Care Director (RCD) Sandra Guadarrama.

The Department conducted interviews and reviewed records. Based on the interviews conducted and records review, R1 was on home health and American Care Hospice for pressure injuries care. Pressure injuries were documented in the resident’s hospice care plan and hospice RN stated she believes facility staff provided care to R1. Based on the interviews conducted and records reviewed, the allegation is Unsubstantiated.
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)
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