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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607448
Report Date: 03/08/2022
Date Signed: 03/08/2022 10:23:00 AM


Document Has Been Signed on 03/08/2022 10:23 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MAGNOLIA TREE BOARD AND CARE HOME, THEFACILITY NUMBER:
300607448
ADMINISTRATOR:SABIO, MARILOUFACILITY TYPE:
740
ADDRESS:805 E WILSON AVETELEPHONE:
(714) 538-6046
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 3DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Marilou SabioTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Facility staff contacted Administrator (AD) Marilou Sabio via telephone and AD stated she would not be able to make it to the visit today and gave staff permission to lead the tour and sign the report. LPA observed all required postings on the walls throughout the facility. AD Marilou Sabio has a current administrators certificate that expires on 08/17/2023. LPA was screened and temperature checked before entering the facility. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. At 8:30am LPA began the tour of the facility. There were three residents in care at the facility. All Client rooms have the necessary requirements, night stand, chair, lamp and storage space. Bathrooms were operational and clean. In Bathroom #1 LPA measured the water temperature at 70 degrees Fahrenheit. The facility has a two day supply of perishable food items and seven days supply of nonperishable food items. There was a first aid kit equipped with all required items in the locked medication closet. The stove was clean and all four burners were operational. At 8:55am LPA observed knives and sharp objects in an unlocked drawer in the kitchen. All hazardous chemical are locked and out of reach. The facility has adequate PPE supply of gloves, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed a swimming pool that meets title 22 regulations. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the residents in care. At 9:10am while touring the back yard with staff, LPA observed some clutter near the rear fence in the pool area. LPA advised staff the importance of keeping the backyard clear and free of clutter. Staff stated that the clutter will be removed and she will provide pictures once complete. All smoke detectors were tested and are operational. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted and a copy of the report was provided to the facility staff Vera.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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 3


Document Has Been Signed on 03/08/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAGNOLIA TREE BOARD AND CARE HOME, THE
FACILITY NUMBER: 300607448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e)Water supplies and plumbing fixtures shall be maintained as follows:
(2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
Deficient Practice Statement
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Based on observation of the water temperature in resident bathroom at 70 degrees F, the licensee did not comply with the section cited above, which poses a potential health or safety/personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Water temperature will be adjusted to meet title 22 regulations.
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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 03/08/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAGNOLIA TREE BOARD AND CARE HOME, THE
FACILITY NUMBER: 300607448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.
Deficient Practice Statement
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Based on observation of knives and sharp objects unlocked in a kitchen drawer accessible to residents, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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All knives and sharp objects will be locked up and inaccessible to residents in care.
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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3