Complaint Investigation Report, 10/14/2025 — Magnolia Place, Bakersfield CA

157208940-10-14-2025-24-AS-SMOA-DMVLZD-20251028091144

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

09/02/2025 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20250902110224

Memory Care Director Kristen Mcmillian and Director Resident Services Mandy House

Facility staff did not follow reporting requirements

Facility staff did not provide adequate supervision, resulting in a physical altercation between residents

Facility staff did not adhere to admission agreement

Facility staff did not ensure resident received diabetic care as needed

Facility staff did not dispense medications as prescribed

Facility staff did not ensure resident was treated with dignity

On 10/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Memory Care Director Kristen Mcmillian and Director Resident Services Mandy House who stated Executive Director Mireya Melchor is unavailable to attend meeting.

During the course of the investigation, the Department conducted interviews, toured the facility, and records were reviewed. Adequate staff were present during altercation between R1 and R2. Staff responded immediately to the incident. Incident was reported to the department in a timely manner. Based on records reviewed and interviews conducted, R1 had a one on one staff prior to residing at the facility. R1 continued one on one staff after residing at the facility. R1 is a diabetic that is on a regular diet with low salt diet. R1’s blood sugar was being checked according to doctor’s order. Interviews and records reviewed confirm, staff administered R1’s mediation as directed. R1 participants with facility activities.

Based on records reviewed, interviews conducted and observation, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to Director Resident Services,whose signature on this form confirms receipt of this report.