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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200740
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:55:17 PM

Document Has Been Signed on 11/14/2024 12:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MAGNOLIA GUEST HOME LLCFACILITY NUMBER:
079200740
ADMINISTRATOR/
DIRECTOR:
GENE L. GEPULLE JRFACILITY TYPE:
740
ADDRESS:1639 FAIRWOOD DRIVETELEPHONE:
(925) 483-2610
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Gene L Gepulle Jr, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/14/2024 at 9:10 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Gene L Gepulle at 9:50 AM and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/10/2024. Emergency Disaster Plan was last posted on 07/18/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/14/2024.

At 10:45 AM, LPA reviewed 5 residents records. At 11:35 AM, LPA reviewed 5 staff records. At 12:25 PM, LPA also reviewed Residents medications.

Updated copies of the following documents were requested and reviewed during the inspection:LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance and Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Ardalan GharachorlooTELEPHONE: (510) 286-4201
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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