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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701287
Report Date: 01/03/2025
Date Signed: 01/03/2025 11:53:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241231092412
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: 1DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Juliet NakyonyiTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide a proper eviction notice to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived to conduct a complaint investigation.

Based on records reviewed and interviews with the staff the department finds the allegation to be substantiated the facility did not provide R1 with a legal document to met the regulatory requirements for a 30 day notice or a change of facility use. The information reviewed is dated 12/10/2024 and the facility is requesting R1 be out by 1/10/2025. This does not met the required 60 days written notice to evict a resident due to change of use of the facility. The information reviewed does not support the regulatory requirement to give a 30 day notice.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20241231092412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAGNOLIA RESIDENCE 1
FACILITY NUMBER: 392701287
VISIT DATE: 01/03/2025
NARRATIVE
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These are the standards for a 30 day notice.

(1) Nonpayment of the rate for basic services within ten days of the due date.

(2) Failure of the resident to comply with state or local law after receiving written notice of the alleged violation.

(3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.

(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.

R1 has not violated any of these reason to justify a notice.

Citation given on the attached 9099 D page. The facility was advised regarding information required to met the regulatory requirements for the physician's report. (ambulatory status etc.... )


Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241231092412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MAGNOLIA RESIDENCE 1
FACILITY NUMBER: 392701287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87224(a-i)
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87224(a) Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.
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The Administrator /Licensee shall submit to the department the required information to evict or provide R1 with a reason for a 60 day notice to leave/vacate the facility.
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This requirement is not met as evidenced by records reviewed and interviews conducted. R1 was not given due process for a 30 day notice nor was R1 given an approved by the department a 60 day notice.
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The required information shall be submitted to the department by the close of business on 1/10/2025 for approval to give the approved notice to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3