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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:39:42 PM


Document Has Been Signed on 05/23/2023 04:39 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:
05/23/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:VirginaTIME COMPLETED:
03:05 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 4/28/23

POC's corrected

Deficiencies cleared:


Section Cited: 87303(e)(2)Date Due: 05/12/2023
Plan of Correction:
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. 		Corrections:
Cleared By Visit		Clearance Date:
05/23/2023


All deficiencies from the visit on 4/28/23 have not been cleared.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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