547209193-6-30-2023-24-AS-SMOA-CTTJM5-20230717070945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 06/29/2023
Date Signed: 06/30/2023 03:38:44 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
03/29/2023 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20230329134637

FACILITY NAME:	MAGNOLIA PARK ASSISTED LIVING		FACILITY NUMBER:	547209193
ADMINISTRATOR:	X,X		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	59	CENSUS: 31	DATE:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Executive Director (ED) Shelly Ramon; Resident Care Director (RCD) Sandra Guadarrama.		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not provide a resident privacy while changing;

INVESTIGATION FINDINGS:

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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 a tour of the facility, reviewed records, and conducted interviews. During the tour, it was observed that residents were afforded privacy. The Department did not receive any specific incidents or complaints from resident. The allegation is Unsubstantiated. Exit interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (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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