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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397001473
Report Date: 02/22/2022
Date Signed: 02/23/2022 08:18:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211223161606
FACILITY NAME:J & R MAGSAYO HOMEFACILITY NUMBER:
397001473
ADMINISTRATOR:JUDIE & REDENTOR MAGSAYOFACILITY TYPE:
735
ADDRESS:2452 S. FRESNO AVENUETELEPHONE:
(209) 466-4584
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
02/22/2022
UNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Rebecca LumandazTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility does not have an adequate supply of food
Food is not adequately stored
Menu posted in the facility is not being followed
Residents do not have access to snacks
Staff is not following precautions to prevent the spread of illness
INVESTIGATION FINDINGS:
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**This report was amended to add citations which are attached on the 9099D.

Based on records reviewed and interviews conducted the facilty did not have an adequate supply of food. During inspection visits on multiple days and LPA's observation it appears that the food supply is insufficient and does not meet the scheduled menu items. Parties observed a posted menu that was not being followed and sustitutions were not being noted. Also observed were the supply of food in the home that did not meet the 2-day supply of fresh foods requirement. The facility had many containers in the refrigerator and freezer that could not be identified and staff stated they all contained food that belonged to staff. The facility staff showed an additional refrigerator that contained mostly staff food. The facility did not have snacks available for residents (including fresh fruits or foods that could be eaten without being cooked). The pantry with dry goods was locked with a padlock and was removed by staff upon request and remains unlocked.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
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-20211223161606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
85076(d)(1)
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The licensee shall meet the following food supply and storage requirements: Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. The licensee shall meet the following food supply and storage requirements: Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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Facility will do an in-service on food monitoring and food preparation, and keeping up to date menus. Facility will email LPA in-service training documents and sign in sheet by POC Date
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This requirement was not met as evidenced by observation were the supply of food in the home did not meet the 2-day supply of fresh foods requirement. This is a potential health and safety concern.
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Type B
03/04/2022
Section Cited
CCR
80076(a)(5)
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 Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request
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Facility will do an in-service on food monitoring and food preparation, and keeping up to date menus. Facility will email LPA in-service training documents and sign in sheet by POC Date
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This requirement was not met as evidenced by observation it appears that the food supply is insufficient and does not meet the scheduled menu. This poses an portential safety concern for the 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211223161606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: J & R MAGSAYO HOME
FACILITY NUMBER: 397001473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
80076(a)(4)
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80076 (a)(4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician. This requirement was not met as evidenced by
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Facility will do an in-service on food monitoring and food preparation, and keeping up to date menus. Facility will email LPA in-service training documents and sign in sheet by POC Date
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pantry with dry goods was locked with a padlock. This poses a personal right issues for the 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3