<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:52:04 AM

Document Has Been Signed on 11/18/2022 11:52 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: 5DATE:
11/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Virginia RagasaTIME COMPLETED:
11:47 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Albert Johnson arrived to conduct an unannounced case management visit. LPA met with staff and informed them that the reason for this case management visit is to make the facility aware of the fact that R1 will be returning to the facility today.

LPA Johnson made contact with the Administrator/Licensee at approximately 10:00 a.m. this morning to inform the facility that R1 was illegally evicted and R1 has the right to return to her residence.

R1 out to the ER to be assessed for health concerns. The facility did not pick-up or make for arrangements for R1 to come back to her home after the hospital assessed R1 and determined that she would be placed on hospice. The information given to the discharge planner at the ER was that R1's family was given a 30 day notice and that the hospital should call the family to determine where R1 should be discharged to. The family did pick up R1 and has been providing care for R1 at their residence.

Deficiencies were not issued today, the department issued citations on 11/17/2022 for the complaint #27-AS-20220919105510.

Exit interview. Copy of report provided to facility representative.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 1