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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006193
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:40:52 AM

Document Has Been Signed on 08/22/2022 11:40 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MAGNOLIA TREE HOMEFACILITY NUMBER:
306006193
ADMINISTRATOR:TAWFIK, FATEN FOUADFACILITY TYPE:
735
ADDRESS:633 S. PEPPER STREETTELEPHONE:
(714) 488-9212
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: 0DATE:
08/22/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Faten Tawfik, Administrator/Licensee
Magdy Tawfik, Licensee
Abir Elyousfi, Licensee		TIME COMPLETED:
11:15 AM
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Component II completion: Successful

Facility Type: Adult Residential Care Facility (ARF)
Application Type: Initial
Capacity: 4 all ambulatory
Census (if any clients in care): none
COMP II Participants: Faten Tawfik, Administrator/Licensee
Magdy Tawfik, Licensee
Abir Elyousfi, Licensee
Interview Method: Telephone interview

On August 22, 2022, Licensees and Administrator participated in COMP II. Identification of Licensees and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensees and Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Licensees and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator and Licensees. Report sent via email and required to return signed copy back to CAB with copy of pre-licensing checklist.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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