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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209193
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:36:47 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
02/13/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240213085245
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
UNANNOUNCEDTIME 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
ALLEGATION(S):
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Resident AWOL from the facility because of lack of supervision
INVESTIGATION FINDINGS:
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An Office visit was conducted on this date to discuss the complaint and deliver findings. LPA, LPM, and RM met with facility staff to discuss the above allegations.

The Department conducted interviews and reviewed records. R1 has dementia and AWOL from the facility without staff knowledge. Police was informed and relocated the resident. The above allegation is Substantiated.

Exit Interview was conducted and appeal right was given.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20240213085245
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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87411(a)
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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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Discuss during NCC.
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Based on interviews conducted and records reviewed, R1 left the facility and AWOL, without staff knowledge, which poses an immediate health and safety risk to the resident 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) -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
LIC9099 (FAS) - (06/04)
Page: 2 of 2