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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005642
Report Date: 10/19/2020
Date Signed: 10/19/2020 01:26:04 PM

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 CARE HOMEFACILITY NUMBER:
397005642
ADMINISTRATOR:LEILA B YEEFACILITY TYPE:
740
ADDRESS:4727 SONGWOOD CTTELEPHONE:
(209) 982-1457
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
10/19/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Leila Yee, LicenseeTIME COMPLETED:
11:30 AM
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On 10/19/2020 at 11:00am, CCLD Sacramento South conducted a conference call with the Licensee. Present for the call was Licensing Program Analysts (LPAs) Ashley Boothe, Diego Escobar, Licensing Program Manager (LPM) Liza King, and Jill Hernandez from San Joaquin Long Tern Care Ombudsman. The purpose of this meeting is to discuss citations issued on the previous annual inspection conducted on
02/05/2020.

Issues discussed during the meeting were:

1. Visitor screening procedures
2. Medication Storage
3. Vector Control
4. Storage of disinfectants and cleaning solutions.

Licensee reviewed the plan of correction for each item listed above.

COVID-19 mitigation plan was requested from licensee. CCLD will contact Licensee to provide additional technical assistance.


Exit interview conducted with Licensee. Copy of the report was provided. Licensee is to print out the LIC 809 and fax a signed copy to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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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