<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006056
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:23:48 PM


Document Has Been Signed on 02/14/2024 02:23 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 PALMSFACILITY NUMBER:
306006056
ADMINISTRATOR:BHATIA, KIMFACILITY TYPE:
740
ADDRESS:17397 PALM STREETTELEPHONE:
(949) 433-0599
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Renato Pabilane, Caregiver and Kim Bhatia (Via telephone)TIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called Licensee/Administrator (L/AD) Kim Bhatia and explained the nature of the visit.
This facility is licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory Residents of which 1 (one) may be bedridden in Room #3 only, and has a hospice waiver for five (5) residents. There are no residents in care receiving hospice care services at this time. There are no active COVID-19 cases in the facility at this time. Administrator Kim Bhatia has an Administrator Certificate with expiration date of 7/23/2023. (L/AD) Bhatia indicated pending renewal certificate and agreed to submit copy upon receiving AD certificate to CCL.
LPA Rosie Quiroz along with (CG1) toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed four of four residents in care watching television in living-room area with staff supervision. LPA Quiroz interacted and interviewed with staff, residents and visitor during today's visit.
During today's visit, LPA Quiroz reviewed 4 of 4 residents files, medication records and 2 of 4 staff records. (See LIC 9102 Advisory Note)
The water temperatures were recorded to be between 106.6-109.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating in the backyard for residents and visitor's enjoyment in backyard area.
During today's inspection visit, LPA Quiroz observed closet remodeling in room #3, this was verified with (L/AD) Bhatia via telephone. During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control with (L/AD) Bhatia via telephone. (See LIC 9102 Advisory Note)
CONTINUED ON NEXT PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5


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 PALMS
FACILITY NUMBER: 306006056
VISIT DATE: 02/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED...An exit interview was conducted with (L/AD) Bhatia via telephone and a copy of this report, LIC 811- Confidential names, LIC 9102 TVs were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5