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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701287
Report Date: 06/29/2023
Date Signed: 07/17/2023 02:50:51 PM


Document Has Been Signed on 07/17/2023 02:50 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 RESIDENCE 1FACILITY NUMBER:
392701287
ADMINISTRATOR:RIVERA, JOSHUAFACILITY TYPE:
740
ADDRESS:941 WEST WILLOW STTELEPHONE:
(209) 981-3584
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY:6CENSUS: 0DATE:
06/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Joshua RiveraTIME COMPLETED:
04:30 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
On 6/29/23 at approximately 1:45pm Licensing Program Analysts (LPAs) Jensen and Fain arrived at facility unannounced to conduct a pre-licensing visit. LPAs Jensen and Fain met with applicant Joshua Rivera and explained the purpose of today's visit. There are currently no residents in the facility.

The facility is a single story structure with 3 bedrooms, 2 baths, kitchen, common area and mud room. There is a raised deck in the back yard and stand alone garage that is currently being used for storage. LPAs Jensen and Fain toured the interior and exterior of the facility. The facility was observed to have adequate furniture and lighting throughout.

The 3 resident bedrooms were furnished with chairs, night stands, lamps and either a dresser or clothing closet. The mattresses have protective sleeves and are in good condition. The facility maintains an adequate supply of linens. Night lights are available in the hallways. The water temperature was measured at 111.6 degrees Fahrenheit which is within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. The bathrooms are equipped with grab bars in the shower and by the toilet. Trash cans throughout the facility have tight fitting lids.

Fire clearance has been approved for 1 bedridden and 5 non-ambulatory residents. The smoke detector was tested and found to be in good working. The fire extinguisher was last serviced in July of 2022 and is in compliance. The facility maintains an emergency supply kit that is complete with scissors, tweezers, thermometer, various wound dressings and manual.

LPAs Jensen reviewed documents needed for resident files and determined them to be in compliance.
All required signage was posted where it can be easily viewed by residents and visitors.
Continued on LIC 809C...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 2


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 RESIDENCE 1
FACILITY NUMBER: 392701287
VISIT DATE: 06/29/2023
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
26
27
28
29
30
31
32
LPAs Jensen and Fain toured the facility grounds. There is a large covered front deck with seating and also a back deck that is furnished. There are shaded areas in the front and back. There are no bodies of water on the property, All window screens were observed to be in good repair. The facility keeps a variety of activities on site for resident engagement.

The Licensee will send the liability insurance by fax or email to the Department by 7/13/23.

The facility was observed to be in substantial compliance and has passed the pre-licensing inspection. A Component III presentation was conducted.

An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2