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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:49:27 PM

Document Has Been Signed on 04/20/2023 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
SIERRA CASCADE AC/SC, 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: 125DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie Whitlock.TIME COMPLETED:
01:00 PM
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On 04/20/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and were allowed entry into the facility. LPA met with Administrator (ADM) Paul Anderson and Director of Residential Services (DRS) Shellie Whitlock. LPA discuss the purpose of the inspection. LPA conducted tour of facility with ADM and DRS.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. LPA toured resident bedrooms in Assisted Living and Memory Care. LPA observed 11 of the 132 rooms in the facility. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathrooms hot water temperature was tested range between 109.8 degree F to 110.1 degree F. LPA observed securely fastened grab bars and non-skid mat in all tub/shower areas. Trash bin with lids and hand washing posting was observed. LPA interviewed residents.

LPA toured kitchen to the common areas. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Temperature tested for refrigerator at 40 degree F. and freezer at -1 degree F. Medications were stored in a locked medication room in a medication cart. Medication records and medications were reviewed. First Aid Kit contained the required supplies and stored in the medication room. LPA toured and observed residents in the activity room on the 2nd floor. Fire extinguisher was observed with a service date of: 09/28/22. Last Fire drill completed on 03/27/23. The outside was toured and observed to be free from debris. There was outdoor seating for the residents.

LPA will return to review records and finish the inspection tool.

An exit interview was conducted with ADM and DRS. A copy of this report was discussed and left with the Administrator Paul Anderson, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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