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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208940
Report Date: 04/08/2026
Date Signed: 04/10/2026 02:36:50 PM

Document Has Been Signed on 04/10/2026 02:36 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/
DIRECTOR:		MELCHOR, MIREYAFACILITY TYPE:
740
ADDRESS:8100 WESTWOLD DRIVETELEPHONE:
(661) 663-8400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 146CENSUS: 104DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Mireya Melchor, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 04/08/26, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Annual Inspection. LPA met Administrator (A1) Mireya Melchor. LPA conducted tour Memory care unit with A1 and Director of Resident Services Palvire Bassi. LPA tour Assisted Living unit with A1.

Facility consists of Assisted Living (AL) and Memory Care (MC) Unit.The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. Residents were observed seating in common areas. Facility has sufficient furnishings inside and outside for resident use. Fire extinguisher was observed throughout the facility with a service date of: 08/14/25. Medications were locked in medication cart in the medication room. MARs were reviewed and medications were checked. Cleaning chemicals observed locked in housekeeping closet. LPA toured kitchen. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Walk-in freezer temperature was maintained at 0 degrees F and walk-in refrigerator temperature was maintained at 40 degrees F. Bathrooms hot water temperature was tested. LPA observed securely fastened grab bars. Outside was toured and observed to be free from debris with outdoor seating available for residents. A sample of resident and staff files were reviewed.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421BG.

Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by 04/14/26: Lic 308, Lic 500, Lic 610E, liability insurance, control of property, and currently administrator certificate. A copy of this report and appeal rights was provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/10/2026 02:36 PM - It Cannot Be Edited


Created By: Mai Yang On 04/08/2026 at 02:25 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: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
873559(e)
873559(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility…

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on records reviewed, S1 and S2 are not fingerprinted cleared and not associated to the facility, which poses an immediate risk to the health and safety of the residents.
POC Due Date: 04/09/2026
Plan of Correction
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S1 and S2 were off and left the facility during visit. S1 and S2 are not permitted back until fingerprinted cleared and associated. POC cleared during visit.
Type A
Section Cited
CCR
87309(a)
87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R3 and R4 cannot have access to chemicals. Cleaning chemicals were observed in R3’s bathroom and under R4’s bathroom and kitchen sink unlock, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 04/09/2026
Plan of Correction
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Administrator immediately removed chemicals to lock storage. POC cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2026 02:36 PM - It Cannot Be Edited


Created By: Mai Yang On 04/08/2026 at 02:28 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: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
87465 (d)(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R2’s PRN medication Acetaminophen 650mg order on 08/20/25 was not recorded in the resident’s MAR, which poses an immediate health and safety risk for the person in care.
POC Due Date: 04/09/2026
Plan of Correction
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Staff recorded medication PRN medication Acetaminophen 650mg in R2’s MAR during visit. POC cleared during visit.
Type B
Section Cited
CCR
87633(b)
87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview conducted, the licensee did not comply with the section cited above when LPA reviewed R1’s file who is currently receiving hospice care has no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

POC Due Date: 04/09/2026
Plan of Correction
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Administrator obtain current hospice care plan for R1 from hospice during visit. POC cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2026 02:36 PM - It Cannot Be Edited


Created By: Mai Yang On 04/08/2026 at 02:30 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: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above no non-skid mat and/or strip was observed in the residents’ shower in room 19, room 17, and room 217, which poses/posed a potential health, safety or personal rights risk to person in care.
POC Due Date: 04/14/2026
Plan of Correction
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Proof of non-skid mat or strips in residents’ bathroom shower shall be submitted to the Fresno CCL by POC due date 04/14/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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