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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208940
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:23:16 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
05/26/2022 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220526130257
FACILITY NAME:MAGNOLIA PLACEFACILITY NUMBER:
157208940
ADMINISTRATOR:ANDERSON, PAULFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:146CENSUS: 118DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Paul AndersonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Neglect/ lack of care & supervision resulted in residents engaging in physical altercation causing the resident to sustain fractures
INVESTIGATION FINDINGS:
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On 8/26/22, Licensing Program Analyst (LPA) M. Medina conducted visit to deliver findings on this complaint. LPA met Paul Anderson, Executive Director and stated purpose of visit.

During the course of the investigation, the department conducted interviews and reviewed records. Based on review, on 5/25/22, Resident 1 (R1) and Resident 2 (R2) were in the television room when R1 assaulted R2, resulting in R2 being hospitalized for fractured ribs and pneumothorax requiring a chest tube placement. R1 and R2 had two previous altercations, one of which required R2 to be sent to the hospital. Staff were instructed to supervise residents in the television room however due to insufficient staffing, staff were assisting other residents when the incident occurred.

Based on the above information, the preponderance of evidence standard has been met.
The allegation that lack of supervision resulted in R2 sustaining a fracture while in care is Substantiated.

An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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-20220526130257
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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2022
Section Cited
CCR
87411(a)
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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
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Administrator will submit written plan within 24 hours, that details the steps that will be taken to ensure this regulation is met. The plan shall include a date(s) that staff, including lead
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evidenced by staff not supervising residents in the television room,
resulting in R1 assaulting R2, requiring R2 to be hospitalized for fractured ribs and pneumothorax
requiring chest tube placement. This is an immediate risk to resident health and safety.
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and supervisory, will be trained on personnel requirements within 10 days of the POC due date (9/12/22). Facility shall submit proof of training to licensing when completed.
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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: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
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