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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603442
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:40:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/04/2022 12:40 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MAGNOLIA HOME CAREFACILITY NUMBER:
198603442
ADMINISTRATOR:BAYNOSA, STEPHANIEFACILITY TYPE:
735
ADDRESS:291 MACALESTER DRIVETELEPHONE:
(951) 231-8248
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 4DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Stephanie Baynosa, AdministratorTIME COMPLETED:
12:55 PM
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`Licensing Program Analysts (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Stephanie Baynosa and explained the reason for the visit. LPA and administrator toured the facility together.

Facility is licensed to served 4 clients between the age of 18 and 59 years old which shall be ambulatory. The facility is a single story building in a residential area, with 4 bedroom, 2 bathrooms, a commercial kitchen, 2 dining rooms, garage and backyard with a shed. Carbon monoxide/ smoke detectors were tested and in working condition.

LPAs discussed infection control practices with administrator Stephanie Baynosa, reviewed food supply, reviewed staff files, and reviewed resident medications. Administrator certificate was observed to be current with # 6050518735 and expire 12/10/2022. Last emergency drill conducted 2/20/22.

LPA toured the kitchen and observed sufficient food supplies of 7 days non- perishables and 2 days perishables. Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The backyard are well maintained and has a locked shed for storage. The resident bathrooms are clean, and has the required signs. The hot water temperature measured between 105- 120 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the hall and in garage. Infection control signs were observed throughout the facility.

Due to technical problems Caretools was not able to open during facility inspection. LPA went over the Caretools questions saved to laptop with Administrator.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator Stephanie Baynosa.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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