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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005444
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:26:39 PM


Document Has Been Signed on 08/22/2022 04:26 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
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: 1DATE:
08/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Leila YeeTIME COMPLETED:
04:45 PM
NARRATIVE
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On 8-22-22 at 1:36pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding facility's intent to close. LPA met with Administrator Leila Yee and explained the purpose of the visit. LPA requested the following documents: 60-day notice of closure, closure roster, and relocation evaluations. LPA also conducted a facility observation and determined that only 1 resident is currently residing at facility at this time. LPA also interviewed Administrator. Based on interview it was determine that three residents previously residing at facility passed away. Resident1 (R1) and R2 passed away in July 2022 and R3 passed away on 8-2-22. R4 is the sole resident living at the facility at this time.

It was further determined through interview and record review that Administrator sent a text message to R4's responsible person on 8-2-22 informing individual of intent to close facility. A formal eviction notice was sent to R4's responsible person on 8-10-22, but not sent to licensing per regulatory requirements. In addition, eviction notice did not contain all required regulatory components of eviction notice.

During interview, LPA discovered that death reports were not sent to the Department for R1, R2, and R3 per regulatory requirements.

Based on today's case management visit, deficiencies are cited under Title 22 regulations, Division 6, Chapter 8 and noted on LIC 9099D. An exit interview was conducted with Leila Yee and a copy of this report was left with Leila. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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 08/22/2022 04:26 PM - 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: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited

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Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).(5)Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. (1)...written notice...shall...include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code.
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This requirement is not as evidenced by: Based on interview and record review, licensee issued an eviction notice to R4's responsible person which did not meet the regulatory requirements as specified above.This poses a potential health, safety, and resident rights risk to residents in care.
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Type B
08/31/2022
Section Cited

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Eviction Procedures. (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by:
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Based on interview and record review, licensee issued an eviction notice to R4 on 8-10-22 and did not provide a copy to licensing agency as of 8-22-22. This poses a potential health, safety, and resident rights 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/22/2022 04:26 PM - 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: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(A)Death of any resident from any cause regardless of where the death occurred...This requirement is not met as evidenced by:
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Based on interview and record review, licensee did not send notice of death for R1, R2. and R3. This poses a potential health, safety, and resdient rights risk to resdients 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3