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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830521
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:12:37 AM


Document Has Been Signed on 09/27/2022 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:FSA-MAGNOLIA CDCFACILITY NUMBER:
334830521
ADMINISTRATOR:LESLIE COXFACILITY TYPE:
850
ADDRESS:8172 MAGNOLIA AVE.TELEPHONE:
(951) 353-0129
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:156CENSUS: DATE:
09/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Alondra Rios Dominguez, DIrectorTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kay Turner arrived at the facility to conduct a case management visit regarding the lead testing. Room 4 was closed in or about December 2021 and has not been in use. Currently, there are no immediate plans to reopen. Per the lead sample report submitted to the LPA on or about September 19, 2022, there was a documented level of exceedance in classroom 4. The fixtures were replaced on Friday, September 23, 2022 as part of the corrections plan. Photographs of the updated fixtures were taken and will be placed in the file. The Director reported the request for retesting was submitted yesterday electronically. The sink in classroom 4 will not be used until it meets the lead requirements. The aforementioned resulted in a deficiency, as the documented lead levels exceeded 5.5 ppb and is above the level of exceedance per the Lead Testing Written Directives. Please see 809D for deficiency.


Exit interview conducted and report was reviewed with the Program Director, Alondra Rios Dominguez.

A copy of this report was provided to the Program Director and a Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene TurnerTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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Document Has Been Signed on 09/27/2022 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: FSA-MAGNOLIA CDC
FACILITY NUMBER: 334830521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2022
Section Cited

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(b)(1), A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 

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Per the lead sample report submitted on 09/19/2022, sink/faucet in classroom 4 results were 14.00 UG/L, at the action level of exceedance.
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14

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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.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene TurnerTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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