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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:07:29 PM

Document Has Been Signed on 04/28/2023 02:07 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:
04/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Paul Anderson and Director of Residential Services Shellie Whitlock.TIME COMPLETED:
02:07 PM
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On 04/28/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a continuation of the Required Annual Inspection. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock and stated the purpose of the visit.

A sample of the residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report.

A sample staff files were also reviewed. Staff files were observed to have current First Aid/CPR, Personal Record, and TB results.

No deficiencies issued during this inspection.

An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 5/05/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, Theft and Los procedure/policy, and current Administrator Certificate. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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