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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 03:36:30 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
04/06/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20230406095355
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):
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Staff mishandles the residents medication while in care;
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 reviewed medications, centrally stored medication list, and conducted pill counts of resident’s medications. During the review, pill count for two of R1’s medications were off. R1’s MARs was not updated and dates were left blank with no explanation. The allegation is Substantiated. Exit Interview was conducted. Appeal Rights were provided.
Substantiated
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
Control Number 24-AS-20230406095355
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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility… The licensee shall
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Administrator agrees that a plan for medication administration will be submitted by the due date. The plan will include training
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assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
Based on records reviewed and medication count, two of R1’s medications were off. R1’s MARs was also incomplete.
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 for all caregivers who assist in medication administration and completing the MARs correctly. POC will be submitted by the due date.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC9099 (FAS) - (06/04)
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