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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425812
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:28:30 PM

Document Has Been Signed on 04/07/2023 01:28 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAGNOLIA RESIDENCEFACILITY NUMBER:
336425812
ADMINISTRATOR:CANDANEDO, NITZAFACILITY TYPE:
735
ADDRESS:45015 THALIA LANETELEPHONE:
(951) 226-7391
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 0DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Ivan Varela & Nitza Candanedo, AdministratorsTIME COMPLETED:
01:20 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Magnolia Residence Adult Residential Facility to conduct an annual inspection. LPA was greeted by Staff and invited inside. LPA introduced self and stated purpose of the visit. The staff member identified himself as Ivan Varela, Administrator. LPA was also greeted by Nitza Candanedo, Administrator. LPA was informed there are currently four (4) residents in care, but are not present as they are at their prospective day programs.

LPA conducted a tour of the facility with staff, inside and outside, and observed the following:

Facility: The Facility is licensed for four (4) ambulatory adults, ages 18 -59. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).

Physical Plant: LPA observed the facility's temperatures to be appropriate. The facility was orderly. Showers and toilets are operable. Linens and hygiene items are located on the second floor with ample amounts for the residents in care. Each room is equipped with lamps and appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms, carbon monoxide detectors were tested and found functional. LPA reviewed the facility's Emergency Disaster Plan and Fire Drills. Last fire drill conducted on 2/15/23. Last Earthquake drill conducted on 1/15/23.

Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available for residents. Extra food and Emergency Food supplies are kept in the facility garage. Two (2) refrigerators, and a deep freezer were observed containing additional food for both residents and staff.

Please see LIC809C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAGNOLIA RESIDENCE
FACILITY NUMBER: 336425812
VISIT DATE: 04/07/2023
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Care & Supervision: Facility has sufficient care staff who reside on facility grounds; toxic items are inaccessible to residents in care and stored in cabinets and drawers that can be locked and unlocked using keys.
Record Review and Resident/Staff Files: LPA reviewed records for all four (4) residents currently residing at the facility. Resident records are complete with updated physician reports and Needs and Services Plans. LPA additionally reviewed two (2) staff files and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificates are in good standing.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted in the hallways of the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored in a secure hallway closet. Each resident has their own labeled container containing their medications. LPA reviewed all the residents' medications and compared it to the facility's Medication Administration Report (MARs) and Centrally Stored Medication Log. No medication errors observed.

No deficiencies were cited during this inspection. An exit interview was conducted, this report was discussed then provided to Administrators.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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