<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604648
Report Date: 08/22/2023
Date Signed: 09/29/2023 10:54:07 AM


Document Has Been Signed on 09/29/2023 10:54 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:POWAY GARDENS SENIOR LIVING - MAGNOLIASFACILITY NUMBER:
374604648
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12735 MONTE VISTA ROADTELEPHONE:
(658) 674-1255
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: DATE:
08/22/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Donelle Williams, AdministratorTIME COMPLETED:
04:57 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: Residential Care Facility for the Elderly
Application Type: Change of Ownership
Capacity: 6
Census: Unknown
COMP II Participants: Donelle Williams
Interview Method: Telephone interview

On 8/22/23, applicant(s)/administrator participated in COMP II for the below pending facilities:
Poway Gardens Senior Living-Palms/374604634
Poway Gardens Senior Living-Magnolias/374604648

Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Anna BarriosTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1