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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603588
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:56:36 PM

Document Has Been Signed on 05/03/2023 02:56 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:TELECARE MAGNOLIA HOUSEFACILITY NUMBER:
198603588
ADMINISTRATOR:CASTRO, QUISHAFACILITY TYPE:
772
ADDRESS:1774 ZONAL AVE UNIT DTELEPHONE:
(510) 337-7950
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 16CENSUS: 13DATE:
05/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mariela GorositoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Regional Director of Operations Mariela Gorosito and explained the reason for the visit.
The purpose of the visit is to conduct a Health and Safety Check.
Health and Safety Check is in regards to a self reported SOC 341 involving the sexual abuse of a current resident by a facility staff.
At today's visit a tour of the facility was conducted with LPA along with Regional Director of Operations Mariela Gorosito and the following was observed:
Facility is a 3 story building and on the 1st floor were client rooms 112 and 113.
1st floor also contained laundry room, office coordinator room, team lead's office, dining hall, kitchen, electrical room, Magnolia Spa with lockers for clients and 1 client restroom with shower.
2nd floor contains group room, storage room, 2 client showers with restroom, staff pod with nursing station, janitorial room and client rooms 213-216.
The 3rd floor contained group room with computers, television, and telephones.
There were 2 client showers with restroom, staff pod with lounge, linen closet and client rooms 313-316.
File for Client 1 was reviewed and the following documents were submitted:
Client Face Sheet, Admission Agreement, ID and Emergency Information, Personal Rights, and Physician's Report.
Staff and client roster was submitted.
Law enforcement arrived at 12:30 AM on 05/03/2023. Incident # 5473.

Based on the available information reviewed, further investigation is needed.

Exit interview conducted with Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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