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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001473
Report Date: 01/02/2026
Date Signed: 01/02/2026 11:15:01 AM

Document Has Been Signed on 01/02/2026 11:15 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:J & R MAGSAYO HOMEFACILITY NUMBER:
397001473
ADMINISTRATOR/
DIRECTOR:		CHERRYL MAGSAYOFACILITY TYPE:
735
ADDRESS:2452 S. FRESNO AVENUETELEPHONE:
(209) 466-4584
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
01/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Tor rendentorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM, Liza King arrived unannounced to the facility at 5:15am to conduct a annual inspection. The LPA and LPM met with the administrator, Tor Rendentor and explained the purpose of the visit. facility has 6 capacity, five in the current census, and no restricted condtions, eveybody is ambulatory.

Physical Plant was inspected, including the bedrooms, bathrooms, kitchen, common areas, storage areas, exterior, and the evacuation route gate. facility is clean, traffic areas are well lit and unobstructed.

Bedrooms have required furniture and furnishings, including mattress encasements.

Bathrooms have functional hardware, the water temperature is measured at 120*F.

Kitchen has adequate lockable storage for sharps and toxics and medication, there is some rice in the rice cooker from the day before. 2 days of perishable food, 7 days of non perishable food is adequate for 5 clients. Some freezer burned foods, a moldy cheese that was asked to be thrown away. unmarked leftovers should be dated once Opened/stored. LPM asked to label the foods immediately.
Common areas and exterior have furniture in good repair, space for activities, and are free of trip hazards.

The evacuation route gate swings freely and latches closed.

The smoke alarm is functional, fire extinguishers are past due Admin went and recharged during visit.
First aid kit had all components. Evacuation binder exists.

Continued on C page
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473
VISIT DATE: 01/02/2026
NARRATIVE
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P+I was checked for 5 clients, found to be in accordance with the amount on the balance sheet. 2 of 5 reciepts were reviewed to ensure purchases were for clients.

5 of 5 Client files were reviewed, including recent medical assessments, ipps, health screenings, admission agreements and MARs. Client Mars are not signed as distributed to 1/1/25 and 1/2/26. two medications are signed as distributed for a period of time, however the count was off. R1 had a prn medication that was given routinely for the period reviewed Sept thru Dec 2025, statement from Admin is this has not been communicated with the PCP. R2 had a medication that was not documented on the MAR but being given for the period reviewed. Additionally pm medications were present for 12/28/25 and not given, no documentation as to why and another routine medication was given daily and not documented on the MAR.
One client has no ipp, administrator provides its finished in his car. client files are otherwise present and up to date.

5 of 5 Staff files were reviewed, including trainings for continuation and initial for related topics of care, first aid/cpr, and firnger printing. One staff is missing a tb clearance and first aid training, Administrator provided the staff has not recived the training, she is new. LPA gave guidance that the staff cannot work a shift alone until the first aid is complete. staff files are otherwise present and up to date.

Administrator file was reviewed, including certification, facility posters(ombudsman, license, facility sketch, administrator certificate, federal workers rights, and client rights). surety bond, infection control plan, evacuation control plan. present and up to date.

LPA asked to be sent a copy of the grievance policy, deed, and the refund policy from the plan of Operation, 1/5/26. noel.wolfpetersen@dss.ca.gov.

2 staff interviews, 4 client interviews.

citations issued, a copy of the report was read and given to the administrator. appeal rights provided, exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/02/2026 11:15 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 01/02/2026 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of R2s MARS for the period reviewed (Sept 2025 to current) a medication was given daily however the medication is not documented on the MARs for the months of Sept, November and January). Additionally medications for 12/29/25 were still in the bubble pack. No clear explation as to why the medications were missed was provided which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Admin agreed to have all staff that provide medications participate in an initial medication training course. Please submit proof of training to Noel.WolfPetersen@dss.ca.gov
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of R1s medication record, prn medication has been given daily for the period reviewed Sept 2025 to current. Per the Admin, this has not been discussed with the MD. This presents an immediate H&S risk to clients in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Admin agreed to have all staff that provide medications participate in an initial medication training course. Please submit proof of training to Noel.WolfPetersen@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/02/2026 11:15 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 01/02/2026 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of R1s record the facility failed to document any of the required elements for prn medications this poses an immediate resik to clients in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Admin agreed to have all staff that provide medications participate in an initial medication training course. Please submit proof of training to Noel.WolfPetersen@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/02/2026 11:15 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 01/02/2026 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the stored food in the refridgerator and freezer the facility failed to label opened food and store in sealed packaging which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Facility labeled all food during visit and agrees to do so moving forward. No further action needed.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review 2 of 2 clients centrally stored logs the facility failed to complete the logs accuratly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Admin agreed to have all staff that provide medications participate in an initial medication training course. Please submit proof of training to Noel.WolfPetersen@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2026


LIC809 (FAS) - (06/04)
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