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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001473
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:35:12 PM

Document Has Been Signed on 04/25/2024 03:35 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: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:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Redentor MagsayoTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 4-25-24 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding regulation 80087(g) Buildings and Grounds. LPA met with staff member Redentor Magsayo and explained the purpose of the visit. During today's visit regarding a previous complaint allegation follow up, LPA observed various lawn equipment, sharp objects, gasoline, and cleaning solutions accessible to residents in care. Objects were accessible in the backyard near the sliding glass door exit and inside a non-working refrigerator which was not locked and accessible to residents. LPA also observed a locked storage area with additional items placed therein. LPA conducted brief interview with staff member who confirmed objects are used by resident1 (R1) for various yard work projects.

As result of today's case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Redentor Magsayo and a copy of this report was provided to Redentor. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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Document Has Been Signed on 04/25/2024 03:35 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/25/2024 at 02:34 PM
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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
80087(g)

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80087 Building and Grounds. (g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Staff secured dangerous items during LPAs visit.

Licensee to submit a plan ensuring on-going inaccesiblity of chemicals, sharp object, and other dangerous objects. Plan to be submitted to LPA by POC due date.
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Based on observation, Licensee did not ensure client inaccessiblity of various chemicals and sharp objects which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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