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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:49:30 PM

Document Has Been Signed on 08/26/2022 12:49 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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Francine ReyesTIME COMPLETED:
12:58 PM
NARRATIVE
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On 8/26/2022, Licensing Program Analysts (LPA) M. Medina arrived to conduct a Case Management visit related to concerns reported to Department. The concerns were reported to Department during an unrelated Complaint Investigation.

LPA introduced self and stated purpose of visit. LPA met with Francine Reyes, Director of resident services.

Facility toured. During the course of complaint investigation conducted it was observed that the air conditioning in room #10 was not working properly and the toilet seat in resident bathroom #1 was missing.

Deficiencies cited on the attached 809-D.

Exit interview conducted. A copy of this report was provided for facility records.
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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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/26/2022 12:49 PM - It Cannot Be Edited


Created By: Melinda Medina On 08/26/2022 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
08/26/2022
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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During subsequent facility tour on 8/26/22. LPA observed air conditioning unit in room #10 to have been replaced and working properly. The toilet seat in resident bathroom #1 to be replaced
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**This was not met as evidenced by . During the course of a prior complaint investigation conducted it was observed that the air conditioning in room #10 was not working properly and the toilet seat in resident bathroom #1 was missing.
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DEFICIENCY CLEARED AT TIME OF CASE MANAGEMENT VISIT.

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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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