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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006193
Report Date: 09/30/2024
Date Signed: 09/30/2024 04:18:13 PM

Document Has Been Signed on 09/30/2024 04:18 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MAGNOLIA TREE HOMEFACILITY NUMBER:
306006193
ADMINISTRATOR/
DIRECTOR:		FATEN TAWFIKFACILITY TYPE:
735
ADDRESS:633 S. PEPPER STREETTELEPHONE:
(714) 395-6956
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Faten Tawfik, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1PM. During today’s visit, LPA met with Faten Tawfik, Administrator.

The facility is a Level 4i single story building with four bedrooms and an approved fire clearance of four ambulatory. The facility currently has a census of four clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices on all exits, The hot water temperature measured between 105.2 and 106.7 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on May 2, 2024. The facility’s last fire drill was conducted on June 6, 2024. All client bedrooms had the required furnishings and were clean.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. All knives were secured on the medication cart and cleaning solutions locked underneath the sink. LPA observed medication storage and reviewed the centrally stored medications. The First Aid Kit had the necessary items with a First Aid Manual. Per review medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records. LPA conducted a complete review of client records. Client P&I records were reviewed. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 27, 2025.
(See LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MAGNOLIA TREE HOME
FACILITY NUMBER: 306006193
VISIT DATE: 09/30/2024
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(Continued from LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Faten Tawfik, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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