197606109-3-13-2024-31-AS-LCAS-D3BR2R-20240313123845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606109
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:38:55 PM

Document Has Been Signed on 03/13/2024 12:38 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MAGNOLIA MANOR		FACILITY NUMBER:	197606109
ADMINISTRATOR:	JEANETH T. CRISTOBAL		FACILITY TYPE:	740
ADDRESS:	20648 BLACKHAWK ST.		TELEPHONE:	(818) 701-0016
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 2	DATE:	03/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jeaneth Cristobal		TIME COMPLETED:	01:00 PM

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At 10:15 am Licensing Program Analyst (LPA), Lorena Casillas, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator Jeaneth Cristobal, who granted access to the facility and LPA explained the reason for the visit.

At 10:45 am, LPA conducted a tour of the facility, and the following was observed:

Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signs were observed along the hallway and in the restrooms.

Kitchen: At 10:50 am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum of seven days and perishable for two days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen that was last serviced on 03/20/23.

Bedrooms: There are four (4) bedrooms designated for resident use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 10:55 am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet paper, soap, and paper towels. The hot water temperature measured at 107.7 °F. LPA observed grab bar and non-skid mats. LPA also observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Continued on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAGNOLIA MANOR	FACILITY NUMBER: 197606109
	VISIT DATE: 03/13/2024

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Common Areas: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished. No obstructions or tripping hazards throughout the facility.

Outside areas: At 11:00 am LPA toured the outside area of the facility. There is a swimming pool that is fenced all around with a gate and kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. LPA also observed a clean covered patio and furniture to accommodate residents.

Garage: Laundry area is in the attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage were also observed.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:00 am they were tested and observed to be operational.

Administrative: LPA collected Resident Roster and LIC500. Certificate of Liability Insurance will be emailed to LPA. Annual fee is due by 03/30/2024 LPA gave Administrator PIN. Administrator will pay fee by due date.

Resident Interviews: At 12:00 pm LPA interviewed residents.

Staff Interviews: At 12:10 pm LPA interviewed staff.

Medications: At 12:20 pm LPA and Administrator went over medications.

No citations issued during this visit. Exit interview conducted. Copy of report given to Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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