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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:45:14 AM


Document Has Been Signed on 07/15/2022 11:45 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MAGNOLIA CARE HOME 1FACILITY NUMBER:
392701190
ADMINISTRATOR:SOUMAHORO, MARIAM G.FACILITY TYPE:
740
ADDRESS:4727 SONGWOOD COURTTELEPHONE:
(209) 982-1457
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
07/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Virginia Ragasa and Aida FontanillaTIME COMPLETED:
12:00 PM
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Licensing program Analyst (LPA) Albert Johnson conducted a pre-licensing inspection on 7/15/2022.

LPA conducted a tour inside and outside of the care home. LPA observed the back yard with a secure fence, there was a table, umbrella, and adequate outdoor seating, and no pool or bodies of water were observed. LPA observed the back yard and perimeter of the care home to be free of clutter and debris and windows and screens were in good repair Inside the care home, LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed bedrooms and living areas to be adequately furnished and LPA observed adequate supply of linens on hand. Tested water temperature in resident bathroom at 115 degrees F. LPA observed bathrooms to be in sanitary condition and maintained. Cleaning supplies and chemicals are stored in a locked cabinet.

LPA observed a sufficient supply of perishable and non-perishable food supply on hand, and there is a sufficient supply of eating, serving, and food preparation materials on hand as well. LPA observed a first aid kit and fire extinguishers maintained and ready for emergency use and a fire clearance is for six non- ambulatory clients. Smoke detectors are functioning as well as the carbon monoxide detector.

Emergency exit and phone number are posted. There are supplies and materials for activities. Medications and confidential paperwork are stored in separate locked cabinets.

Pre-licensing passed and COMP III completed . Applicant has satisfied all requirements in accordance to per Title 22, California Code of Regulations
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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