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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708852
Report Date: 07/11/2025
Date Signed: 07/16/2025 04:12:13 PM

Document Has Been Signed on 07/16/2025 04:12 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MAGALLANES REST HOMEFACILITY NUMBER:
270708852
ADMINISTRATOR/
DIRECTOR:		MAGALLANES, LYDIAFACILITY TYPE:
740
ADDRESS:193 LILLIAN PLACETELEPHONE:
(831) 917-3584
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 6CENSUS: 1DATE:
07/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee, Lydia MagallanesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Lydia Magallanes Continual Administrator's Certification expired on 07/11/2025. Administrators Certification Bureau shows application for renewal Administrators certificate was submitted on 05/12/2025. There is currently 1 resident who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Residents bedroom is clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational Water temperature was tested at 120 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

LPA observed perishable food being kept at room temperature. LPA observed the facility refrigerator and cabinet area next to the facility refrigerator infested with ants. LPA observed squash and other prepared foods room temperature on counter tops. LPA observed the facility dining area is cluttered. Facility does not have Infection Control Plan available to review or Emergency Disaster Plan LIC610E. Facility does not have required proof of disaster drills. Licensee does not have staff records available to review. Licensee does not have complete Resident records available for review. Admission agreement does not have all required verbiage. Resident 1 does not have current Needs and Services Plan.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Lydia Magallanes, and copy of report left at facility
Brenda ChanTELEPHONE: (650) 266-8800
Sarah HurtTELEPHONE: 559-243-8080
DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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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Document Has Been Signed on 07/16/2025 04:12 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/11/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee could not provide Infection Control Plan for review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee will send Infection Control Plan for review to LPA by POC date of 07/25/2025.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed ants in the facility refrigerator, and in panttry area, and perishable food being stored at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee will clean facility kitchen, and refrigerator and send proof to LPA by POC date of 07/25/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-2131
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 879-2602
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/16/2025 04:12 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/11/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed ants in the facility refrigerator, and in panttry area, and perishable food being stored at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee will clean facility kitchen, and refrigerator and send proof to LPA by POC date of 07/25/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-2131
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 879-2602
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/16/2025 04:12 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/11/2025 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87212(a)

87212 Emergency Disaster Plan

(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the facility does not have the required Emergency Disaster Plan, which poses an immediate personal rights risk to persons in care.
POC Due Date: 07/12/2025
Plan of Correction
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Licensee will submit LIC610E Emergency Disaster Plan and submit to LPA by POC date of 07/12/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (650) 266-8800
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 559-243-8080
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
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