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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440810
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:36:55 PM


Document Has Been Signed on 05/30/2023 03:36 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MAG'S REST HOMEFACILITY NUMBER:
011440810
ADMINISTRATOR:SANTILLAN, LORNA & DANILOFACILITY TYPE:
740
ADDRESS:6002 BELLHAVEN AVENUETELEPHONE:
(510) 795-0775
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:8CENSUS: 3DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Danilo SantillanTIME COMPLETED:
03:45 PM
NARRATIVE
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On this day at around 9:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Darlina Osalla and explained the purpose of visit. Administrators Danilo and Lorna Santillan arrived at a later time.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, dining area, garage and backyard. Facility has an approved fire clearance for 8 non ambulatory residents.

Upon arrival, LPA observed 3 residents in the facility. Hot water measured at 116.5 F in the common bathroom. LPA observed a fire extinguisher that appeared full and was inspected on 1/3/2023. Carbon monoxide was tested and observed functional. Administrator states smoke detectors are interconnected with the hoe ADT. Medications were observed locked in a medication cart in the kitchen. There was sufficient supply of perishable and non perishable foods. Passageways were observed free from any obstruction.

At 10:55 am, LPA reviewed First Aid kit and observed it to be complete and updated. At 11:50 am, LPA reviewed 3 staff and 3 resident files. At 11:30am, LPA reviewed medication and Medication Administration Record (MAR). At 3 pm, LPA interviewed 1 staff and 2 residents. Last fire and earthquake drills were conducted on May 4, 2023.

During records review, LPA observed facility does not have liability insurance and staff on duty does not have current CPR.

Type B deficiencies were cited per Title 22 California Code of Regulations (Refer to Lic 809D).

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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Document Has Been Signed on 05/30/2023 03:36 PM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MAG'S REST HOME
FACILITY NUMBER: 011440810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in failing to maintain liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2023
Plan of Correction
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By POC date, Administrator will obtain required liability insurance and submit proof to CCL.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not ensuring that the caregiver on duty has a CPR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2023
Plan of Correction
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By POC date, Administrator will have staff obtain CPR training and submit proof to CCL.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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