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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701287
Report Date: 08/05/2024
Date Signed: 08/05/2024 11:24:45 AM


Document Has Been Signed on 08/05/2024 11:24 AM - 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: 2DATE:
08/05/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Juliet NakyonyiTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced Post Licensing inspection on this date.

LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

The licensee will remove all bedding items from the storage area and send a picture to confirm that the items have been removed. The licensee will have staff files available for review during each visit from licensing.(Advisories given).

The Licensee will report deaths as defined in 87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.


Exit interview held with Administrator/via phone and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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