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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 05/12/2023
Date Signed: 05/23/2023 04:37:30 PM


Document Has Been Signed on 05/23/2023 04:37 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:
05/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Virginia RagasaTIME COMPLETED:
02:52 PM
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 (LPA) Albert Johnson arrived to the facility and met with Staff to conduct POC Inspection from 809 and 809-D dated 4/28/23

POC's corrected

Deficiencies cleared:

Section Cited: 87705(c)(5)Date Due: 05/19/2023
Plan of Correction:
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.
Corrections:
Cleared By Visit
Clearance Date:
05/12/2023
Section Cited: 87705(I)(8)Date Due: 04/29/2023
Plan of Correction:
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.
Corrections:
Cleared By Visit
Clearance Date:
05/12/2023
Section Cited: 87411(c)Date Due: 05/12/2023
Plan of Correction:
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.
Corrections:
Cleared By Visit
Clearance Date:
05/12/2023

All deficiencies from the visit on 4/28/23 have not 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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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 1