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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700561
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:43:56 PM

Document Has Been Signed on 12/16/2021 02:43 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:J & R MAGSAYO HOME IIIFACILITY NUMBER:
392700561
ADMINISTRATOR:MAGSAYO, REDENTORFACILITY TYPE:
735
ADDRESS:1528 VENETIAN DRTELEPHONE:
(209) 598-6098
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Redentor MagsayoTIME COMPLETED:
02:37 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check.

LPA confirmed that staffing is sufficient today and there are no unmet needs for the residents in care. The facility is staffed to provide no gaps between shifts all staff are live-in.

The department will be on a scheduled a telephone/Teams meeting on Monday, time to be determined. The department has requested that the facility provide copies of the LIC 500 and LIC 308.

Health and Safety check has concluded for today. The overall safety of the facility including food supply, physical plant and staffing.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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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