Inspection Reports for Magnolia Crossing Assisted Living

This was an unannounced complaint investigation visit triggered by a complaint received on 2025-04-07 regarding the facility's failure to provide a resident file as requested.

The investigation substantiated that the facility did not provide a copy of the resident file to the resident or responsible party within the required two business days, violating Health and Safety Code 1569.269(a)(21). The delay posed a potential risk to residents' health, safety, or personal rights.

The complaint was substantiated based on interviews and records review. The facility failed to provide requested resident records within the required timeframe, violating Health and Safety Code 1569.269(a)(21).

The inspection was a required annual unannounced visit conducted by Licensing Program Analysts to evaluate compliance with regulatory requirements.

The facility was toured inside and out, including checks of water temperatures, fire extinguishers, kitchens, medication storage, bedrooms, and smoke/carbon monoxide detectors. All required documentation was reviewed and found to be updated and in place. No deficiencies were cited during this inspection.

Licensing Program Analysts conducted an unannounced visit to the facility to perform an Annual Inspection.

The Licensing Program Analysts toured the three facility buildings with the Administrator and completed a file review for staff and clients. Documentation of the facility tour was done separately.

An unannounced visit was conducted to check the facility and records to verify that an employee named Tiana Gilbert was not employed or present on the premises.

The individual named Tiana Gilbert has not been employed at the facility since January 5, 2024, and was only employed for approximately two weeks in 2023.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-05-29 regarding staff neglect, medication mishandling, inadequate care, and facility maintenance issues.

The investigation found insufficient evidence to substantiate the allegations related to resident care and medication administration, resulting in an unsubstantiated finding. Additionally, allegations regarding pest control and facility maintenance were found to be unfounded with no deficiencies cited.

The complaint investigation was unsubstantiated for allegations including staff neglect causing a resident fracture, improper medication handling, inadequate care and supervision, failure to report incidents, insufficient staff training, failure to prevent altercations, delayed response to resident alerts, and delayed medical attention. The allegations regarding pest control and facility maintenance were found to be unfounded.

The visit was an unannounced case management incident inspection to discuss an incident reported on September 26, 2024, involving a staff member using inappropriate language toward a resident.

The investigation found that a staff member spoke inappropriately to a resident by calling them a derogatory name, which posed a potential immediate health, safety, or personal rights risk. The staff member was terminated, and a citation was issued for a personal rights violation.

The visit was complaint-related due to an incident report alleging inappropriate language used by a staff member toward a resident. The allegation was investigated, and although the administrator could not confirm the events, the staff was terminated. A citation was issued for personal rights violation.

An unannounced Case Management visit was conducted to assess the facility's compliance and resident health status.

No deficiencies were observed or cited during the visit. The facility's exits were open and free of obstruction, and no hazards were noted.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-26 regarding staff not safeguarding residents' personal belongings, inadequate food service, failure to notify authorized representatives of condition changes, and untimely assistance with bathing.

The investigation found no supportive evidence to substantiate any of the allegations. Observations, interviews, and record reviews indicated that staff safeguarded belongings, provided adequate food service, notified representatives appropriately, and assisted residents with bathing in a timely manner. No deficiencies were cited.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred. Allegations included failure to safeguard belongings, inadequate food service, failure to notify authorized representatives, and untimely bathing assistance.

The inspection visit was an unannounced continuation of the annual inspection to evaluate compliance with licensing regulations.

Deficiencies were cited related to food service requirements, specifically the improper storage of soaps, detergents, and cleaning compounds with food supplies. A Plan of Correction was developed with the administrator during the exit interview.

The visit was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.

The Licensing Program Analyst toured the facility, checked water temperatures, fire extinguishers, kitchens, medication storage, bedrooms, and smoke detectors. No deficiencies or citations were issued at this time due to time constraints, and the inspection will be completed on a later date.

The visit was an unannounced complaint investigation triggered by allegations received on 2023-12-01 regarding staff mistreatment and neglect of residents at Magnolia Crossing facility.

The investigation included interviews, observations, and record reviews. No preponderance of evidence was found to substantiate the allegations of rough handling, emotional abuse, lack of assistance with ambulating, personal care, incontinence needs, or inappropriate speech by staff. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint included allegations of staff handling residents roughly, emotional abuse, failure to assist with ambulating, personal care, and incontinence needs, and inappropriate speech to residents. The investigation found no substantiated evidence to support these allegations.

An unannounced complaint investigation visit was conducted in response to allegations received on 2023-10-13 regarding medication administration, assistance with physical therapy, mobility needs, and modified dietary needs at Magnolia Crossing facility.

The investigation found insufficient evidence to substantiate the allegations. It was unclear whether staff failed to administer medications, assist with physical therapy, or assist with mobility needs. The complaint regarding modified dietary needs was found to be unfounded. No deficiencies were cited.

The complaint was unsubstantiated/unfounded after investigation. Allegations included failure to administer medications as prescribed, failure to assist with physical therapy and mobility needs, and failure to meet modified dietary needs. No preponderance of evidence was found to prove violations.

The visit was a case management follow-up on SOC341 conducted by the Licensing Program Analyst to review resident files and assess compliance.

During the visit, the resident file for R1 was reviewed and no citations were issued. The report was provided to the Administrator.

Unannounced complaint investigation visit conducted in response to allegations that staff did not seek medical attention for a resident and did not dispense residents' medication as prescribed.

The investigation found that the Medication Administration Records contained several errors and it was unclear if medication errors or lack of medical attention occurred. Based on interviews and documentation reviewed, both allegations were unsubstantiated due to insufficient evidence.

The complaint was unsubstantiated. Although the allegations may have occurred, there was not a preponderance of evidence to prove the alleged violations did or did not occur.

The visit was a Case Management - Other type inspection conducted to review the facility's medication administration records and overall medication tracking system.

The Licensing Program Analyst observed that the facility's medication tracking system was unorganized, with missing medication technician signatures, extra signatures, and crossed out information on medication administration records without proper documentation. Technical assistance was provided to the administrator.

An unannounced complaint investigation visit was conducted in response to allegations including staff using profanity toward residents, falsifying resident records, engaging in inappropriate activities in front of residents, multiple residents developing stage 4 pressure injuries due to lack of repositioning, staff not providing meals, and a resident's dog disrupting others.

The investigation included interviews, observations, and record reviews. No evidence was found to substantiate the allegations. Residents and witnesses did not report or observe the alleged behaviors or conditions. The complaint was determined to be unsubstantiated or unfounded due to lack of evidence.

The complaint was unsubstantiated and unfounded. Allegations included staff using profanity, falsifying records, inappropriate activities, failure to reposition residents causing pressure injuries, failure to provide meals, and a disruptive resident's dog. The reporting party was anonymous and no contact information was provided for follow-up. Evidence did not support the allegations.

The visit was conducted in response to a resident document received, focusing on case management and deficiencies related to medical assessments for residents in the memory care facility.

The inspection found that two residents in dementia care did not have their annual medical assessments completed as required by Title 22 regulations, posing a potential health and safety risk.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff provided care while under the influence of marijuana, failed to maintain infection control practices when handling medication, and did not distribute residents' medications as prescribed.

The investigation found all allegations to be unsubstantiated or unfounded due to lack of sufficient evidence. No violations were confirmed regarding staff impairment, infection control, or medication distribution.

The complaint investigation was unsubstantiated for allegations of staff providing care while under the influence of marijuana and failing to maintain infection control practices. The allegation that staff did not distribute medications as prescribed was found to be unfounded.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were restricting residents' visitors.

The investigation found the allegation to be substantiated. Facility staff did not allow a visitor (Witness 1) to visit Resident 1 despite the resident's consent and no legal restriction on visitors, posing an immediate health, safety, or personal rights risk.

The complaint alleged that staff were restricting residents' visitors. The allegation was substantiated based on interviews, documentation, and evidence reviewed.

An unannounced complaint investigation was conducted following a complaint received on 05/25/2023 alleging that staff did not ensure facility ovens were working properly.

The Licensing Program Analyst conducted interviews and toured the facility, observing all six ovens operational and heating up. The allegation was found to be unfounded and without reasonable basis.

The complaint was investigated and found to be unfounded.

An unannounced case management - other inspection was conducted related to complaint #24-AS-20230525082016 to verify staff association and compliance with licensing requirements.

The Licensing Program Analyst found that the Administrator and staff member S1 were not previously associated with the facility but had completed required criminal record clearances during the inspection. No deficiencies were cited. The licensee was advised to submit paperwork for the change of Administrator and to pay annual renewal fees within specified timeframes.

Inspection was conducted in response to complaint #24-AS-20230525082016. The complaint involved verification of staff association with the facility. No deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by allegations including staff administering medication while under the influence and medication missing.

The investigation found the allegation of staff administering medication while under the influence to be unsubstantiated due to lack of evidence. The allegation of medication missing was found to be unfounded after review and interviews, with no deficiencies issued during the inspection.

The complaint investigation involved two main allegations: 1) Staff administering medication while under the influence, which was unsubstantiated, and 2) Medication missing, which was unfounded after investigation.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-21 regarding staff inappropriately handling residents and using inappropriate words towards a resident.

The investigation substantiated the allegations that staff were inappropriately transferring and speaking aggressively to residents, with staff working outside their usual areas due to COVID-related staffing issues, posing a potential health and safety risk to residents.

The complaint was substantiated. The allegations of inappropriate handling and verbal abuse by staff were confirmed through interviews and observations. The preponderance of evidence standard was met.

Unannounced visit/investigation of a complaint received on 2021-10-21 regarding allegations of resident falls, delayed medical attention, improper medication administration, and forced medication.

The investigation found that although the resident had a history of falls and was on hospice care, the injuries were treated by hospice and not due to lack of care or supervision. Medication administration was as prescribed with a PCP order to crush medications. The allegations were unsubstantiated based on the preponderance of evidence.

Complaint investigation was unsubstantiated. Allegations included resident falls resulting in injury, staff not seeking timely medical attention, improper medication administration, and forced medication. The evidence did not meet the Department's standard for substantiation.

The inspection was an unannounced required infection control inspection conducted due to the facility having positive COVID staff and residents.

The infection control practices were found to be in compliance with no deficiencies cited. Technical assistance was given for masking and trash bins.

Unannounced complaint investigation visit conducted in response to allegations that staff yelled at and rough handled residents in care.

Based on interviews and records review, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Exit interview was completed and appeal rights were given.

The complaint investigation was unsubstantiated. Allegations included staff yelling at residents and rough handling residents. The investigation included interviews with staff and residents and review of physicians reports, special incident reports, staff schedules, and written statements.

The visit was an unannounced complaint investigation triggered by a complaint received on 07/06/2020 alleging that hygiene items were not provided at the facility.

The investigation included interviews and records review conducted via teleconference due to COVID-19 precautions. The allegation was found to be unsubstantiated as there was not a preponderance of evidence to prove the violation occurred.

The complaint alleged that hygiene items were not provided. The allegation was investigated and found to be unsubstantiated.

The visit was an unannounced complaint investigation triggered by a complaint received on 07/06/2020 alleging dirty facility floors, dirty resident bathroom, and inadequate food service.

The investigation found the complaint to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis. The complaint was dismissed after discussion with the facility administrator.

Complaint was investigated and found to be unfounded. Allegations included dirty floors, dirty bathroom, and inadequate food service. Complaint was dismissed.