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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:36:09 AM


Document Has Been Signed on 02/13/2024 11:36 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
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: DATE:
02/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Meshell Ramos, Director of Operation Shawn Amirhoushand and Chief Operating Officer Mark PeperTIME COMPLETED:
12:00 PM
NARRATIVE
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A Non-Compliance Conference was completed on this date. LPA, LPM, and RM met with facility staff.

The following issues were discussed and cited.

The following citations will be issued during today’s meeting:
* 87405(d)(2) Administrator - Qualifications and Duties - Knowledge of and ability to conform to the applicable laws, rules and regulations.
* 87207 False Claims - No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Administrator stated during the 2/2/23 Informal Office meeting that the uncleared Maintenance guy was removed. Interview conducted on 1/6/24 indicated the uncleared maintenance guy was working at the facility and left alone with residents.
* 1569.185(e) - 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. Licensee was informed on 1/6/24 that annual fees were overdue and given a POC. To date, the fees have not been paid. Immediate Civil penalty for repeat citation is assessed.

Licensee Representative stated that they will add a management company.

TSP was offered and accepted by Licensee Representative.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/13/2024 11:36 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
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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87207

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* 87207 False Claims - No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Administrator stated during the 2/2/23 Informal Office meeting that the uncleared Maintenance guy was removed. Interview conducted on 1/6/24 indicated the uncleared maintenance guy was working at the facility and left alone with residents.
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Discuss during the NCC.
Type A
02/14/2024
Section Cited
CCR
87405(d)(2)

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Administrator - Qualifications and Duties - Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Discuss during the NCC.
Type B
02/14/2024
Section Cited
CCR1569.185(e)

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Fees for license or applications; use of revenues; collected; denial or forfeiture.

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Discuss during the NCC.

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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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2