300607448-10-24-2023-22-AS-CGUZ-CWWUR5-20231024154809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300607448
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:48:17 PM

Document Has Been Signed on 10/24/2023 03:48 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MAGNOLIA TREE BOARD AND CARE HOME, THE		FACILITY NUMBER:	300607448
ADMINISTRATOR:	SABIO, MARILOU		FACILITY TYPE:	740
ADDRESS:	805 E WILSON AVE		TELEPHONE:	(714) 538-6046
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 2	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Marilou Sabio		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Vera Manligas. LPA discussed the purpose of the inspection and Administrator (AD) Marilou Sabio was contacted by phone and arrived at 1:15 p.m. During the inspection LPA, Staff Manligas, and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with three resident bedrooms, three bathrooms, and two staff bedrooms. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and two residents present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 120.3 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps were observed locked with medication. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication closet was observed to be locked. LPA reviewed two out of two resident files and three staff files. During staff file review, LPA observed staff present did not have a current, unexpired CPR and first aid card and AD does not have a current, unexpired AD certificate, and was unable to provide LPA with copies of documents submitted to CCL for AD certificate renewal; two Deficiencies were cited during today visit. LPA interviewed staff and residents present.

Based on the observations made during today’s inspection, two deficiencies are 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 Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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Document Has Been Signed on 10/24/2023 03:48 PM - 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and AD admission, the licensee did not comply with the section cited above, as two out of two staff present do not have current, unexpired CPR cards, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	AD stated staff will complete CPR and first aid training immediately and staff training will be conducted to ensure CPR and first aid cards remain current and unexpired. AD will provide LPA with proof of POC via email by POC date.

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on AD interview and record review, the licensee did not comply with the section cited above, as AD does not have a current, unexpired AD certificate and was unable to provide LPA with copies of documents submitted for certification renewal which poses a potential personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	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 kept on hand and are available upon request.

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 Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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