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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201415
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:39:07 PM

Document Has Been Signed on 11/13/2024 03:39 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 GARDEN ASSISTED LIVINGFACILITY NUMBER:
079201415
ADMINISTRATOR/
DIRECTOR:		OLIVA, JOSEPH ANTHONYFACILITY TYPE:
740
ADDRESS:205 EL PINTO ROADTELEPHONE:
(510) 364-5158
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 36CENSUS: 19DATE:
11/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Backup Administrator, Heidi YrreverreTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/13/2024 at 12:00PM, Licensing Program Analysts (LPAs) A. Gomez and K Nguyen arrived unannounced to conduct Pre-Licensing inspection. LPA met with Backup Administrator, Heidi Yrreverre and explained the purpose of the visit. Applicant arrived later during visit. The facility currently has 19 residents and is approved for 4 bedridden.

LPAs toured the facility with the Administrator . Physical plant is consistent with the facility sketches submitted to Centralized Application Bureau (CAB). There is no body of water. Bedrooms were observed appropriately furnished with adequate lighting. Supplies of towels, bed sheets, linens were adequate. Equipment and supplies for residents' personal hygiene were available and on site. Food supplies were observed adequate for seven days of non-perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storage where knives and medications is centrally stored was observed.

Fire extinguisher inspected April 12, 2024. Random residents bathrooms hot water temperature was tested and measured at 111.8, 110.3, 107.4, and 113 degrees Fahrenheit. Carbon monoxide and smoke detectors were observed operational.

report continues on LIC 809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MAGNOLIA GARDEN ASSISTED LIVING
FACILITY NUMBER: 079201415
VISIT DATE: 11/13/2024
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LPAs observed the following:

Ripped screen in room 29 sliding door
Room 20 needs Oxygen signs
Food is not being stored properly in kitchen
Kitchen staff has no indicators for residents with special diets
Hot water dispenser that is dangerously hot to touch located in Activity/Dining Area
Laundry room being used for other storage
Outside gates and doors need to be locked
Update all resident
Update all staff files.

Applicant to submit proof by December 2, 2024 showing all the 9 items are corrected.




LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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