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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700561
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:52:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/20/2022 04:52 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: DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Redentor MagsayoTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a required 1-year annual visit. LPA Jensen met with Licensee/Administrator Redentor Magsayo and explained the purpose of today's visit. Redentor holds a current Administrator certificate # 6014649735 which expires on 4/11/24.

The facility is a single story building with 5 bedrooms. 4 of 5 bedrooms are designated for clients and 1 of 5 bedrooms is designated for staff. The facility currently houses 4 residents of which 2 are non-ambulatory. Every resident bedroom has an exit door to the outside. During the course of the visit LPA Jensen engaged with both clients and staff members. The facility was clean, sanitary, free of odor and in good repair. The grounds were well maintained and free of debris. There is a single designated entry point with COVID signs posted and a screening table set up. LPA Jensen was not screened upon entering and 3 of 3 staff observed were not wearing masks. LPA Jensen toured the facility including 4 of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, staff room and grounds. The facility was observed to have adequate lighting, including night lights and adequate furnishings that were in good repair for the comfort of the residents. The thermostat was set at 75 degrees which falls within the required regulatory range. The hot water in 2 of 2 bathrooms and the kitchen was measured and also falls within the required regulatory range. The bathrooms were equipped with grab bars and non-slip mats in the bath/shower.

An activity schedule and the LIC 610 was prominently posted. The LIC 610 was reviewed and in compliance. The facility was observed to have a first aid kit that was complete with but not limited to scissors, tweezers, thermometer, manual, wound care and sterile dressings. The fire extinguisher was last serviced on 7/2/22 and is in compliance. The carbon monoxide detector was tested and is in good working order. The fire drill log was reviewed and LPA Jensen observed that fire drills are conducted monthly.

Continued on LIC 809C.................
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 04:52 PM - It Cannot Be Edited


Created By: Maja Jensen On 07/20/2022 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: J & R MAGSAYO HOME III
FACILITY NUMBER: 392700561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited
CCR
80076(a)(1)

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(a) In facilities providing meals to clients, the following shall apply:

(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.
This requirement was not met as evidenced by:
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Licensee disposed of all expired food during the course of the visit and in the presence of the LPA. Licensee counseled staff on food safety during the course of the visit and in the presence of the LPA therefore no further plan of correction is required.
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Based on LPA's observation of expired carrots, chees and moldy tomato. This poses an immediate health and safety risk to resident's in care.
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Type A
07/20/2022
Section Cited
CCR80072(a)(2)

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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:...
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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Licensee and all staff members all put on masks at the LPA's request. Licensee counseled all staff, in the presence of the LPA, that masks must be worn at all times. Licensee agrees to conduct a PPE and donning and doffing training with all staff members by 8/3/22 and will submit evidence by email
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LPA Jensen was not screened for COVID-19 upon entry and observed all staff members and Licensee to be without a mask inside of teh facility. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: J & R MAGSAYO HOME III
FACILITY NUMBER: 392700561
VISIT DATE: 07/20/2022
NARRATIVE
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Toxins and hazardous objects such as knives were observed to be locked and inaccessible to residents. Medications were observed to be locked and inaccessible to residents. Snacks were observed to be available and easily accessible to residents. A 30 day supply of PPE was observed to be maintained at the facility. An emergency supply of food and water was observed to be maintained at the facility. There was an adequate supply of clean linens available for residents. The facility had fresh fruit available and in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The refrigerator had expired food products including a tomato with evidence of mold growth, several packages of cheese that expired 6/19/22 and carrots that expired 3/6/22.

LPA Jensen reviewed 4 of 4 staff files and observed them to be complete. Facility handles P & I monies, LPA reviewed the P&I money logs for 4 of 4 residents and determined the log is maintained correctly and there is no commingling of funds.

Deficiencies are cited as a result of today's visit from the California Code of Regulations, Title 22, Division 6. See corresponding LIC 809-D.

An exit interview was conducted and a copy of this report along with appeal rights was given to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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