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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607448
Report Date: 12/22/2023
Date Signed: 12/22/2023 09:00:01 AM


Document Has Been Signed on 12/22/2023 09:00 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: 2DATE:
12/22/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Zenaida AguinaldoTIME COMPLETED:
09:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Zenaida Aguinaldo. At 8:27 a.m. Administrator (AD) Marilou Sabio was contacted by phone and the purpose of the inspection was discussed.

LPA is following up on deficiencies cited on 10/24/23, during facility’s annual inspection. Deficiency 1569.618(c)(3) was cited due to two out of two staff present not having current, unexpired CPR cards. During today’s inspection, LPA confirmed both staff present have CPR and first aid cards, with expiration dates of 10/26/25. Deficiency 87412(d) was cited due to AD not having a current, unexpired AD certificate and being unable to provide LPA with copies of documents submitted for certificate renewal. On today’s date, AD was also unable to provide LPA with a current, unexpired AD certificate and was unable to provide copies of documents submitted for certificate renewal; a Deficiency is being cited.

One out of two deficiencies previously cited will be cleared.

Based on today’s observations, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 2


Document Has Been Signed on 12/22/2023 09:00 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: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87412(d)

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The licensee shall maintain documentation that an administrator has met the certification requirements... Administrator Certification Requirements or the recertification requirements...

This requirement is not met as evidenced by:
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AD stated they will provide LPA with proof of documents submitted for AD certificate via email by POC date. AD stated they will ensure copies of documents submitted to CCL are available upon request.
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AD was unable to provide LPA with a current, unexpired AD certificate and was unable to provide copies of documents submitted for certificate renewal which poses a potential health, safety, and personal rights risk to person's in care
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
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