547209193-1-8-2024-24-AS-SMOA-CZDMGP-20240111083614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 01/06/2024
Date Signed: 01/08/2024 10:34:04 AM

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
07/03/2023 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20230703111907

FACILITY NAME:	MAGNOLIA PARK ASSISTED LIVING		FACILITY NUMBER:	547209193
ADMINISTRATOR:	RAMOS, MESHELL		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	59	CENSUS: 20	DATE:	01/06/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Resident Care Director (RCD) Sandra Guadarrama		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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9

Staff do not ensure resident's hygiene needs are being met.
Staff are mismanaging resident's medication log.

INVESTIGATION FINDINGS:

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10
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An unannounced Complaint 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 Department conducted interviews and reviewed records. Interviews conducted and medical records reviewed stated that R1 was left with feces all over his body and left on the floor after a fall for more than thirty minutes. LPA reviewed medications and centrally stored list was not updated and resident was missing medication. MARs were incorrect. Based on the interviews conducted and records reviewed, the above allegations are Substantiated.

Citations are issued per CCR codes Title 22 and issued on this date under complaint number 24-AS-20230711085250. Exit interview was conducted and Appeal Rights were provided.

Substantiated

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: 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)

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