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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 01/06/2024
Date Signed: 01/08/2024 10:30:35 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/08/2024 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: DATE:
01/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Resident Care Director (RCD) Sandra GuadarramaTIME COMPLETED:
01:45 PM
NARRATIVE
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An unannounced Annual was conducted on the date & times indicated above by Licensing Program Manager (LPM) S. Moua, Licensing Program Analyst (LPA) K. Kaur, & Licensing Program Analyst (LPA) K. McClurg. LPM & LPAs met with Resident Care Director (RCD) Sandra Guadarrama.

The Annual Required visit was conducted in conjunction with a complaint inspections.
During the course of the Annuals, LPAs and LPM reviewed resident’s records and medications.

The following deficiencies were observed and cited under the complaints:
1) Resident’s files are incomplete with incorrect information
2) MARs were incorrect and medications were not administered as prescribed

The Department's Licensing Information System (LIS) Facility Transaction History report CLF551M0 reviewed during visit. Per report, the facility’s Annual Fees have not been paid & are overdue. A citation was issued on this date on the attached 9099-D.

Due to time constraints, the physical plant tour of the facility will continue at a later date.


Exit interview conducted with RCD. Report provided. Facility Transaction History report CLF551M0 provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
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 01/08/2024 10:30 AM - 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
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: 01/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2024
Section Cited
HSC
1569.185(e)

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Fees for license or applications; use of revenues; collected; denial or forfeiture.
The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.
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Licensee to bring account current prior to due date.
Facility Transaction History report CLF551M0 provided. Report reflects amounts due & information to pay on-line @ cdss.ca.gov
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This requirement was not met by: Facility has overdue Annual and Late Fees.
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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: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
LIC809 (FAS) - (06/04)
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