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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 08/25/2023
Date Signed: 08/25/2023 01:23:22 PM


Document Has Been Signed on 08/25/2023 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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: 26DATE:
08/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Resident Care Director Sandra Guadarrama and Health Services Director Christine Fernandez TIME COMPLETED:
01:45 PM
NARRATIVE
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On 8/25/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced for complaint inspection and conducted a case management in conjunction. LPA met with Health Services Director Christine Fernandez and announced the purpose of the visit. Executive Director was out of the office. Resident Care Director Sandra Guadarrama was contacted and arrived a short time after.

LPA conducted a tour of the facility with Health Services Director Christine Fernandez. At 10:28 AM LPA toured the facility kitchen and observed several canned goods and boxed items to be expired. At 11:46AM LPA observed two residents that are not on Hospice, to have full bed rails. Facility is reviewing files for physician’s order for full rails. If no orders are on file; LPA will return at a later date for possible citation of deficiencies.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.

An exit interview was conducted with staff including discussing the plan of corrections. Report signed on-site; printed copy provided with 809D page and appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2023 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAGNOLIA PARK ASSISTED LIVING
FACILITY NUMBER: 547209193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2023
Section Cited
CCR
87555(a)

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87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement was not met as evidenced by:
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Expired food that was identified during visit was discarded. Facility to review all food supplies and discard all expired food items by due date.
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Based on observation, expired food was observed at the facility, which poses an immediate health and safety risk to the residents in care.
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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) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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