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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701287
Report Date: 07/15/2024
Date Signed: 07/15/2024 12:24:05 PM


Document Has Been Signed on 07/15/2024 12:24 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 3DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:MJ SamaniegoTIME COMPLETED:
12:30 PM
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On 7/15/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with MJ Samaniego and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. 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 measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.
Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications locked in each section of the facility. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. Fire drill was completed on 3/2024.

The following forms need updating and submitted to CCLD by 07/20/2024:
LIC 308 - Designation of Administrative Responsibility
LIC 500 - Personnel Report
LIC 610E - Emergency Disaster Plan

First aid kit was checked and is complete. No deficiencies were cited.

Exit interview conducted
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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