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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700561
Report Date: 07/13/2023
Date Signed: 07/13/2023 03:57:07 PM

Document Has Been Signed on 07/13/2023 03:57 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: 4DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Redentor MagsayoTIME COMPLETED:
04:05 PM
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On 7/13/23 at approximately 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Redentor Magsayo and explained the purpose of today's visit. The Licensee is also the Administrator and holds current Administrator's certificate # 6014649735 which is good through 4/11/2024.

LPA Jensen toured the grounds and observed all passages to be clear and free of obstruction. There is a wrought iron gate at the entrance to the grounds and access to the backyard from either side of the structure. The facility has sufficient outdoor furniture and shaded areas for use by the clients. All window screens were observed to be in good repair. There are no bodies of water on the premises.

LPA Jensen toured the physical plant and observed the facility to be sanitary, adequately lit and adequately furnished. The thermostat reading was 76 degrees Fahrenheit which falls within the required regulatory range. The current census is 4 and there are 4 bedrooms. Each bedroom is equipped with a night stand, dresser, chair and reading lamp. The mattress have protective covers and the facility maintains an adequate supply of linens. There are night lights available in the hallways. The bathroom water temperature was measured at 112 degrees Fahrenheit which falls within the required range.

LPA Jensen inspected the kitchen and observed all knives and toxins to be locked and inaccessible to residents in care. The facility maintains a 2 day supply of perishable food and 7 day supply of non-perishable food. There are a variety of snacks available to residents located in an unlocked pantry and there there are fresh fruits available including oranges, apples, bananas and pear.

LPA Jensen observed all required postings within the facility including but not limited to Rights of Individuals with Developmental Disabilities,facility sketch, Emergency Disaster Plan, and Activity Calendar.
Continued on LIC 809C....


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 392700561
VISIT DATE: 07/13/2023
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The facility maintains a current surety bond for $3000 good through 09/30/2026. LPA Jensen reviewed the P&I funds and determined the record keeping to be accurate. LPA Jensen reviewed 4 of 4 client files and determined them to be complete. LPA Jensen 2 staff files and determined them to be complete. LPA Jensen interviewed 1 staff member and 1 client.

The facility maintains a first aid kit that is complete with scissors, tweezers, thermometer, manual and various wound dressings. The fire extinguisher was last serviced in June of 2023 and is in compliance. The smoke detector and carbon monoxide detector were determined to be in good working order. There is emergency lighting maintained at the facility. The last fire drill was conducted on 7/2/23.

LPA Jensen requested and received the LIC 500 and the current surety bond. The Licensee will email a copy of the current liability insurance to maja.jensen@dss.ca.gov.

The inspection tool was used during the course of this visit. The facility was determined to be in substantial compliance. No citations were issued.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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