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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 01/06/2024
Date Signed: 01/06/2024 11:54:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
07/11/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20230711085250
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: 20DATE:
01/06/2024
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Resident Care Director Sandra GuadarramaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained injury due to lack of supervision.
Staff left a resident unattended on the floor for extended period of time.
Residents are eloping due to lack of supervision.
Staff did not dispense a resident's medication as prescribed.
Staff are not keeping accurate resident records.
INVESTIGATION FINDINGS:
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The Department conducted interviews and reviewed records. Interviews conducted and medical records reviewed stated that R1 was left with feces all over his body, left on the floor after a fall for more than thirty minutes, and facility had deficit knowledge or resident’s medications. MARS reviewed were incorrect. Medical records documented that R2 had bruising and discoloration to the left eye and shoulder and care staff were educated on redirecting R2 when resident eloped and attempted to get out of the gate. Police call for services documented disturbance with no incident reports submitted.

Based on the interviews conducted and records reviewed, the above allegations are Substantiated. Citations are issued per CCR codes Title 22 and immediate civil penalties for care and supervision and repeat medication errors. Exit interview was conducted and Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20230711085250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:
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Deficiencies will be addressed during NCC meeting.
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Based on interviews conducted and records reviewed, R1 was left in feces by care staff and left on the floor after a fall for more than 30 minutes and R2 sustained an injury to the left eye and shoulder and eloped outside of the facility, which poses an immediate health, safety, and personal rights risk to the resident. Immediate civil penalty is assessed
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Type A
01/07/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility…The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Deficiencies will be addressed during NCC meeting.
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Based on interviews conducted and records reviewed, residents’ medications were not administered as prescribed and MARs were incorrect, which poses an immediate health and safety risks to the residents. Immediate civil penalty for repeat citation is assessed.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230711085250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
87506(a)
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87506(a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidenced by:
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Deficiencies will be addressed during NCC meeting.
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Based on records reviewed and interviews conducted, resident’s files were not made readily available to CCL, which poses a potential health and safety risk.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3