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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 09/20/2022
Date Signed: 10/12/2022 04:18:17 PM


Document Has Been Signed on 10/12/2022 04:18 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: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:
09/20/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Virginia Ragasa TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived to the facility and met with Staff to conduct POC Inspection from 809 and 809-D dated 8/29/22

During the visit on 8/29/2022, LPA Johnson requested the facility to conduct a staff in-service pertaining to medication storage and toxins (topic, instructor, date, time, names, signatures) and provide to LPA via email by 8/30/2022, as well as send hot water temperature logs over the course of the next 7 days to clear the cited deficiency and finally the facility will conduct a fire drill and send proof of that a fire drill was conducted to CCL by the POC due date.

All deficiencies from the visit on 8/29/2022 have been cleared.


Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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