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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700561
Report Date: 08/16/2024
Date Signed: 08/19/2024 04:58:54 PM

Document Has Been Signed on 08/19/2024 04:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:J & R MAGSAYO HOME IIIFACILITY NUMBER:
392700561
ADMINISTRATOR/
DIRECTOR:		MAGSAYO, REDENTORFACILITY TYPE:
735
ADDRESS:1528 VENETIAN DRTELEPHONE:
(209) 598-6098
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:49 PM
MET WITH:Mryna Mariano,and Shermy VilloTIME VISIT/
INSPECTION COMPLETED:
03:02 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 department confirmed that fire safety concerns have been addressed. .

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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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