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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005444
Report Date: 07/15/2022
Date Signed: 08/01/2022 09:50:25 AM


Document Has Been Signed on 08/01/2022 09:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MAGNOLIA RESIDENCEFACILITY NUMBER:
397005444
ADMINISTRATOR:LEILA YEEFACILITY TYPE:
740
ADDRESS:941 W WILLOW STREETTELEPHONE:
(209) 451-3850
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY:6CENSUS: 4DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Leila Yee, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) R. Campbell and LPM Liza King conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Leila Yee. The administrator currently holds a certificate (#6004489740) that expires on 05/13/2023. The facility’s fire clearance was approved for 5 nonambulatory and 1 bedridden that has a direct exit.. Upon entry LPA was screened for COVID symptoms, a sign in/sign out procedure was observed as well as facility staff wearing masks.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms of which 3 bedrooms are occupied by the residents and no bedrooms are occupied by staff. A bed is placed in the enclosed porch for occasional staff use, which is labeled a staff room on the facility sketch. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA R. Campbell observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Tour of facility revealed obstructed exits in the backyard, a weak outdoor rail. In addition to various broken furniture items. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Food in the freezer is not dated when opened, TA was provided.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/06/2021. First aid kit was observed to be complete.

cont on next page
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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 08/01/2022 09:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MAGNOLIA RESIDENCE
FACILITY NUMBER: 397005444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited

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The facility shall be clean, safe, sanitary, and in good repair at all times. This was not met as evidenced by:

LPA R. Campbell observed a weak rail, obstructed fire exit, and cluttered broken chairs, commode, cart and other various items outside that are a danger to residents. Insdide,the sink is not draining properly.
Type B
08/15/2022
Section Cited

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 Admission agreements shall specify the following: (1) Basic services, as defined in Section 87101(b), to be made available. (2) Additional items and services which are available. (3) Payment provisions, including the following: (A) Rate for all basic services ...This was not met as evidenced by:
Administrator did not fill out admissions agreement with the amount of monthly rent as required.

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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MAGNOLIA RESIDENCE
FACILITY NUMBER: 397005444
VISIT DATE: 07/15/2022
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LPA reviewed staff record 4 out of 4 files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 4 of 4 residents’ files, which did not contain completed admissions agreements. In addition 3 of 4 resident files did not have the RP or residents signature on the appraisal.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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