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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880930
Report Date: 08/07/2020
Date Signed: 08/07/2020 06:09:41 PM

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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:MAGNOLIA ELDER CAREFACILITY NUMBER:
331880930
ADMINISTRATOR:TRINH, LAMFACILITY TYPE:
740
ADDRESS:45410 BAYBERRY PLACETELEPHONE:
(951) 225-9027
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: DATE:
08/07/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leo Trinh, LicenseeTIME COMPLETED:
03:30 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6

Method: Telephone call with CAB
COMP II Participants:
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Michael BarrazaTELEPHONE: (916) 653-1383
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020
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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