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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 03/05/2024
Date Signed: 03/05/2024 03:55:09 PM


Document Has Been Signed on 03/05/2024 03:55 PM - 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: 27DATE:
03/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director/Administrator (Admin) Meshell Ramos, RDE2 LLC Director of Operation (DO) Shawn Amirhoushmand, Licensed Vocational Nurse (LVN) Christine FernandezTIME COMPLETED:
04:30 PM
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A Case Management visit was conducted on the date & times indicated above by Licensing Program Analysts (LPAs) K. McClurg & K. Kaur. LPAs met with Executive Director/Administrator (Admin) Meshell Ramos, RDE2 LLC Director of Operation (DO) Shawn Amirhoushmand, & Licensed Vocational Nurse (LVN) Christine Fernandez The purpose of this visit was to review issues regarding Medications as previous discussed in NonCompliance Conference (NCC) held on 2/13/2024.

Facility currently has 10 residents in the Memory Care side & 17 in the standard Assisted Living side.
Resident Medications were randomly pulled with corresponding resident Medication Administration Records (MARs) & Centrally Stored Medication & Destruction Records (CSMDRs). Medication itself along with medication documents reviewed. Medications reviewed against MARs & CSMDRs. Pill count conducted on pulled medications.

During this process, the following issues were observed & shared with Admin, DO, & LVN at time of visit:
-Expired Medication being actively dispensed; (R2-Metformin HCL 750mg, Fill date 3/3/2023, Discard by date: 2/27/2024)
-Medication quantities that did not correspond with medication records;
-Medications on premises that were not logged in or listed on CSMDR;
-Medication CSMDR entries incomplete &/or inaccurate;


Continued.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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


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
VISIT DATE: 03/05/2024
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Continued

Additional observations during this visit:
-Kitchen tap delivering hot water at 125 degrees F or higher was not prominently identified by warning signs. Reminders were provided during previous visits.
-Smoke detector/alarm observed to be missing from facility office. Capped wires observed on ceiling. Installed during time of this visit.

Staff training as conducted on 2/27/2024 reviewed.

The Department has reviewed the above items. Noted issues will be reviewed with Admin & CO during office meeting/conference call.

Exit interview conducted with Admin & CO. Report provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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