198603442-4-6-2026-28-AS-BPEA-DSVV7L-20260406161119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603442
Report Date: 04/06/2026
Date Signed: 04/06/2026 04:11:57 PM

Document Has Been Signed on 04/06/2026 04:11 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MAGNOLIA HOME CARE		FACILITY NUMBER:	198603442
ADMINISTRATOR/ DIRECTOR:	BAYNOSA, STEPHANIE		FACILITY TYPE:	735
ADDRESS:	291 MACALESTER DRIVE		TELEPHONE:	(951) 231-8248
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY: 4		CENSUS: 2	DATE:	04/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Stephanie Baynosa - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Felimon Abcede, DSP II and explained the purpose of the visit. The facility is licensed to serve (4) developmentally disabled adult age range 18 through 59, (4) ambulatory of which (1) may be non-ambulatory, bedroom #3 cleared for non ambulatory. At 1:15pm, administrator Stephanie Baynosa arrived and assisted LPA. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The required cleaning and disinfection activities are performed. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. Physical Plant & Environment Safety: This facility is a single story home consists of (4) client bedrooms, (2) bathrooms, living room, kitchen, dining area, attached garage and backyard. There are (2) clients residing in the home, one of which is non ambulatory. Client bedrooms were toured and have sufficient storage space and lighting. Night light is maintained in hallways and passages to non private bathrooms. Knives, cleaning solutions and disinfectants are locked and inaccessible to clients. Cleaning supplies are locked in the garage storage cabinet. Combo smoke detectors and carbon monoxide detectors were tested and operable. No security window bars installed. Laundry area is in the garage. Facility has working telephone service. Water temperature readings are within the required 105 - 120 degrees Fahrenheit. Indoor passageways were kept free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a sitting area with outdoor furniture. There is a locked shed in the side yard to store garden supplies/equipment. Operational Requirements: Staff provide necessary personal assistance and care based on the clients' needs and services plan. The fire extinguisher mounted on the kitchen wall was serviced on April 7, 2026. Surety bond insurance is valid in the amount of $1000 and expires on 12/23/2028. The outdoor activity area in the backyard provides a shaded area and furnished for outdoor use. ***Refer to LIC 809C for the continuation of this report.***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAGNOLIA HOME CARE	FACILITY NUMBER: 198603442
	VISIT DATE: 04/06/2026

NARRATIVE

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Staffing: A total of (11) staff members including the night staff and Administrator provide care and supervision to the clients. Staffing are maintained as specified by San Gabriel Pomona Regional Center. Staff employed are over the age of 18 and have criminal background clearance, and fingerprint cleared.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (4) staff files including
the Administrator. Proof of staff training, health clearance, criminal record clearance and vaccinations are current. Administrator's certificate is valid and expires on 12/10/2026. Administrator has completed HIV/TB training.
Client Records-Incident Reports: LPA reviewed all client files. Client files are maintained at the facility.
Admission agreement, Physician's Report (including TB and Ambulatory Status), IPP, Needs and Services plan, Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the clients.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable
items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas.
Health Related Services: LPA reviewed medication for all clients. The medications are centrally stored and in their original containers. The facility uses Medication Administration Record (MAR) and medications are administered as prescribed. None of the clients use oxygen.
Incidental Medical Services: There are no clients with restricted health condition in the facility.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility conducts an emergency drill at least quarterly for each shift, last drill conducted on 04/01/2026.
Emergency Intervention: Not-Applicable.

No deficiency cited. Exit interview and a copy of this report was provided to Stephanie Baynosa, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC809 (FAS) - (06/04)

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