547209193-11-20-2024-24-AS-MYAG-DB7MSP-20241120085216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547209193
Report Date: 11/19/2024
Date Signed: 11/20/2024 08:53:45 AM

Document Has Been Signed on 11/20/2024 08:53 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 LIVING		FACILITY NUMBER:	547209193
ADMINISTRATOR/ DIRECTOR:	RAMOS, MESHELL		FACILITY TYPE:	740
ADDRESS:	2950 E. DOUGLAS AVE		TELEPHONE:	(559) 625-6001
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY: 59	TOTAL ENROLLED CHILDREN: 0	CENSUS: 17	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Interim Administrator Amanda Chairez and Health and Senior Executive Director Trevin Willis		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	On 11/19/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA was greeted by Health and Wellness Coordinator Betsy Ross and granted entry into the facility. LPA introduce self, stated the purpose of the visit, and requested to meet with Administrator. Interim Executive Director Amanda Chairez was called and arrived shortly and informed Interim Administrator for the facility. Senior Executive Director Trevin Willis arrived shortly during visit. LPA conducted tour with Interim Administrator. All 17 residents were present during inspection. The facility has three buildings which two are currently vacant for remodeling. The facility was observed to be at a comfortable temperature. The facility was observed clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire system in placed throughout the facility. Fire extinguisher was observed in each hallway with a service date of 08/25/23. Cleaning chemicals observed locked under kitchen sink and laundry room. Extra linens observed in hall closet. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Chemical bottle was observed in resident room 6. Carbon monoxide and smoke detectors were observed in each bedroom. All bathrooms were toured and observed properly equipped. LPA observed 8 out of 15 bathrooms with no non-skid mat or strips. Hot water was tested in all bathrooms. 9 out of 15 bathrooms hot water was tested to range from 122.5 to 165.2 degrees F.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 11/19/2024

NARRATIVE

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Medications observed kept locked in medication room. A sample of residents’ MARs were reviewed, and medications were checked. An adequate supply of perishable and non-perishable food was observed stored in the vacant buildings. Walk in refrigerator temperature was maintained at 30 degrees F and freezer temperature was maintained at -4 degrees F. Outside of facility toured and observed to be free of debris. Adequate outside seatings were observed available for residents. A sample of resident and staff files were reviewed.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

Technical Support Program (TSP) assistance was offered to Interim Administrator and Senior Executive Director. Interim Administrator and Senior Executive Director will make a decision and reach out the department regarding acceptance.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/25/24. Forms requested: Lic 308, Lic 500, current liability insurance, and Lic 610E. A copy of this report and appeal rights was provided to Senior Executive Director, whose signature on this form confirms receipt of this report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. At 10:23 AM, LPA observed in resident’s room 6, a Hydrogen Peroxide Topical Solution bottle on the resident bathroom sink unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Senior Executive Director immediately removed Hydrogen Peroxide Topical Solution bottle. POC cleared during visit.

Section Cited

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, multiple expired food was observed in the walk in pantry, poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Senior Executive Director immediately disregarded expired food. POC cleared during visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 08:53 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, R1’s Amlodipine Besylate and Memantine Hcl medication and R2's Aspirin medicaiton was not administered as directed by physician which poses an immediate health and safety risk for the person in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 11/20/24. Licensee shall have all medication technician staff be retrained on administering medications. Licensee will submit documentation of training topics and materials including date, training instructor, and staff attendance rooster to the Fresno CCL office by 12/6/24.

Section Cited

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a service date of 08/25/23, which poses an immediate health and safety risk to the residents.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	All fire extinguishers shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 11/20/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 08:53 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above no non-skid mat or strip was observed in room 1, 6, 7, 10, 11, 13, 14, 15 with no non-skid mat or strips in the bathtub which poses/posed a potential health, safety or personal rights risk to person in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Proof of non-skid mat or strips in the 8 bathrooms shall be submitted to the Fresno CCL by POC due date 11/29/24.

Section Cited

87507 (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when R1, R2 and R3’s admission agreement was not signed and dated for the above facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Facility agrees to update R1, R2, and R3’s admission agreement and sign and date all admission agreements on file by the POC due date. Updated/complete admission agreements will be submitted to the Fresno CCL office by the POC due date of 12/09/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 08:53 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87458(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, R1 and R2 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Licensee will submit proof of TB result for R1 and R2 to Fresno CCL by POC due date 12/09/24.

Section Cited

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, there was no personnel records for S2, and S3. S1 have incomplete personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	All staff personnel records shall be maintained in the facility. S1, S2 and S3’s Lic 501, Lic 503, Lic 508, Lic 9052, TB result, and staff trainings shall be submitted to the Fresno CCL office by the POC due date of 12/09/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 08:53 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303 (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Hot water temperature was tested and 9 out of 15 bathrooms hot water was tested to be between the range from 122.5 to 165.2 degrees F., which poses/posed a potential health and safety risk to the residents in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	The facility shall maintain hot water temperature between 105 degree F and 120 degree F. The facility shall have a daily temperature log to ensure water temperature meets the regulation requirements. Daily temperature log with proof of hot water temperature is tested between 105 degree and 120 degree F shall be submitted to the department by 11/25/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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