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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708749
Report Date: 12/13/2021
Date Signed: 12/17/2021 08:11:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:MAGNOLIA MANOR OF CARMELFACILITY NUMBER:
270708749
ADMINISTRATOR:PEACH, VICTORIAFACILITY TYPE:
740
ADDRESS:26695 PANCHO WAYTELEPHONE:
(831) 625-9488
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 0DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Victoria PeachTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection site visit and met with Victoria Peach Administrator. The facility has not had any residents in care since May of 2018.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Facility has a central entry point and masks and hand sanitizer available to visitors.

Administrator will notify Community Care Licensing upon admission of a new resident.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Victoria Peach Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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