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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006193
Report Date: 09/25/2023
Date Signed: 09/25/2023 04:23:05 PM

Document Has Been Signed on 09/25/2023 04:23 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 TREE HOMEFACILITY NUMBER:
306006193
ADMINISTRATOR:GAMAL TAWFIKFACILITY TYPE:
735
ADDRESS:633 S. PEPPER STREETTELEPHONE:
(714) 395-6956
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Justine Malllari, Gamal TawfikTIME COMPLETED:
04:35 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Justine Mallari and discussed the purpose of the inspection. Administrator (AD) Gamal Tawfik arrived during the inspection.

LPA reviewed Infection Control requirements. At about 1:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 2 staff and 2 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 107 degrees F in the common bathroom and 107 in the bedroom bathroom. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the medication cart. Toxins: observed locked in the kitchen. Medication cart: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed licensing fees with AD. At about 2:30PM, LPA reviewed 4 client files and 4 staff files, interviewed 2 clients and 2 staff, inspected medications for 4 clients, and inspected client money and ledgers for 4 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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 09/25/2023 04:23 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/25/2023 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MAGNOLIA TREE HOME
FACILITY NUMBER: 306006193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents and observation, the licensee did not sure 1 client received all doses of Clonidine, Gabapentin, Docusate Sodium, and Glyburide in September 2023, which poses a potential health risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee stated they will notify the doctor of the error and will retrain staff and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
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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 HOME
FACILITY NUMBER: 306006193
VISIT DATE: 09/25/2023
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During the inspection, LPA and AD observed the following medications were documented as having been given to Client #1 (C1) but the pills were still in the bubble packs: the 09/17/23 12PM doses of Clonidine and Gabapentin; the 09/16/23 and 09/17/23 4PM doses of Docusate Sodium; and the 09/16/23 and 09/17/23 5PM doses of Glyburide.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023
LIC809 (FAS) - (06/04)
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