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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603442
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:15:49 PM

Document Has Been Signed on 04/24/2023 04:15 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
GREATER LA AC/SC, 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: 3DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kristine Jimenez, House ManagerTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with House Manager, Kristine Jimenez. The purpose of the visit was explained. The facility is licensed for (4) adults, ages 18 - 59, of which 1 may be non-ambulatory and is approved for bedroom #3.

The facility consists of 4 bedrooms, 2 bathrooms, living room, dining area, kitchen, and attached garage. The spacious backyard consists of recreation activities for clients and has a shaded area. There are no pools or bodies of water at the premises. The facility is operating within the fire clearance approval. Staff are providing care and supervision to meet the clients' needs and assisting in activities of daily living. There are currently 3 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center. Per house manager, there are 2 staff working in the morning and afternoon shift when all clients are at home and one awake staff in the overnight shift to supervisor clients.
The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting daily and more often for high touched surfaces. The cleaning supplies are locked in the garage storage cabinet. Facility has sufficient PPE supplies. There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Foods are properly stored in the refrigerator to avoid contamination.
LPA reviewed records for 3 staff and they have the required documents in their files such as health screening form, TB test result, Personnel record, employee rights, First Aid/CPR certificate, and training hours. Staff have current first aid and CPR training certificates.
LPA reviewed all 3 client files today. Each of the files has the required documents such as the admission agreement, medical assessment including TB results, and current IPP reports from the regional center. There are no clients who require postural supports at this home.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MAGNOLIA HOME CARE
FACILITY NUMBER: 198603442
VISIT DATE: 04/24/2023
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The facility has an emergency and disaster plan. The plan has at least 2 shelter locations and location of utility shutoff valves. The facility is currently conducting monthly fire drills. LPA informed house manager about the different emergency scenarios drills that shall be conducted at least quarterly for each shift.

No deficiencies were observed during the visit today. LPA provided some technical assistance indicated on the LIC9102 forms. An exit interview was held. A copy of this report along with the LIC9102 forms were given to the house manager.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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