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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 04/28/2023
Date Signed: 05/08/2023 04:32:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/08/2023 04:32 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: 6DATE:
04/28/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Virginia RagasaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual inspection on this date. LPA met with Virginia R.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was not working and being repaired during the visit. LPA was informed today that the hot water went out last night. which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Fire drill was conducted on 8/29/2022.

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 2 staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked. During the file review LPA observed outdated physician's report for R1 as well as an outdated service plan.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Deficiencies were cited during this visit. Advisories were given.

Exit interview held and a report given with appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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 3


Document Has Been Signed on 05/08/2023 04:32 PM - It Cannot Be Edited

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: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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87303(e)(2) Maintenance and Operation -Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105
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Administrator shall have the water heater repaired. Administrator shall test the hot water each day for 3 days and send in the hot water measurement sheet to LPA by the POC due date.
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degree F (41 degree C)
and not more than 120 degree F (49 degree C)-This requirement was not met as evidenced by observation: Hot water measured at 68.5*F in residents bathroom.This poses a potential health and safty risks to residents.
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Type B
05/19/2023
Section Cited

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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All residents diagnosed with dementia will be scheduled with their physician and be assessed for any changes to their needs with an updated LIC 602.
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 LPA observed that R1 diagnosed with dementia didn't have an updated LIC 602
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/08/2023 04:32 PM - It Cannot Be Edited

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: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2023
Section Cited

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87705(I)(8) Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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The facility shall develop and implement a policy regarding fire drill and earthquake drill practices and procedures that include conducting fire drills at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement is not met based on: LPA was observed that the last drill was conducted on 8/29/2022, which posed an immediate risk to residents in care.
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Send copy of updated policy and fire drill log by POC date
Type B
05/12/2023
Section Cited

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All staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. LPA did not observe any documentation of annual staff training for S1 and S2
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Facility representative stated that all staff providing care and supervision to the residents will receive the required annual hours of training. Proof of training to be submitted into CCL by the due date with info regarding trainer, training topics with length of duration, and attendees.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3