<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 07/26/2024
Date Signed: 07/26/2024 06:45:29 PM


Document Has Been Signed on 07/26/2024 06:45 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: 25DATE:
07/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Director/Administrator (Admin) Meshell (Shelly) RamosTIME COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
During a Complaint investigation it was observed that Licensee was not in compliance with California Code of Regulations, Title 22, Section 87211 Reporting Requirements. Therefore a Case Management visit was conducted.

Incident & Death reports for Resident 1 (R1) not submitted to the Department.

Deficiency issued.

Exit interview conducted with Executive Director/Administrator (Admin) Meshell "Shelly" Ramos. Report provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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 07/26/2024 06:45 PM - 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAGNOLIA PARK ASSISTED LIVING
FACILITY NUMBER: 547209193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87211(a)(1)(A)

1
2
3
4
5
6
7
Reporting Requirements.
A written report shall be submitted to the licensing agency…within seven days of the occurrence of any…Death of…resident from any cause regardless of where the death occurred…

Facility did not submit a written report to the department regarding the death of R1
1
2
3
4
5
6
7
Facility has agreed to provide Incident report of hospitalization prior to death & Death report R1. All reports must be complete. Reports to be completed & submitted by due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2