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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 07/22/2021
Date Signed: 09/09/2021 02:47:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/28/2020 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20201228090245
FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:CHAPMAN, MICHAELFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: 95DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Michael ChapmanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not seek appropriate emergency medical care for resident.
Facility did not coordinate care with home health services agency.

INVESTIGATION FINDINGS:
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On 07/22/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegation.

During the course of the investigation, LPA conducted interviews with staff and reporting party. LPA requested documentation from Executive Director evidencing the effort to seek emergency medical treatment due to a change of condition for R1. The facility was unable to provide. LPA conducted review of medical records from hospital and Emergency Medication Services. Records revealed Urgent Care and family of R1 initiated emergency services required.

The Department investigated the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20201228090245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAGNOLIA PLACE
FACILITY NUMBER: 157208940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited
HSC
1569.49(c)(1)
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.The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement was not met as evidenced by: LPA's observation of hospital medical records. Facility did not seek emergency medical treatment for Resident R1 on 11/20/2020, resulting in hospitalization.
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Facility has inserviced all staff on seeking appropriate medical care for residents in the facility. In the case of a change in condition, 911 will be dispatched, Resident's Representative and MD will be notified. ***POC cleared/Civil Penalty Assessed***
Type A
07/22/2021
Section Cited
HSC
1569.80(a)
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(a) A resident of a residential care facility for the elderly, or the resident’s representative shall have the right to participate in decisionmaking regarding the care and services to be provided to the resident. Accordingly... the facility shall coordinate a meeting with... the resident’s representative... an appropriate member...of the facility’s staff, if the resident is receiving home health services in the facility...and a representative of the home health agency involved,. The facility shall ensure that participants in the meeting prepare a written record of the care the resident will receive in the facility...
This requirement was not met as evidenced by interview with Executive Director stating a meeting with Home Health and resposible parties had not happened.
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Facility has conducted staff meeting to include procedures that will ensure a care conference is conducted upon admission to home health services. Resident, responsible party , Home health and LVN of the facility will be present. ***POC Cleared***
CCR
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Type A
CCR
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
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