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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005642
Report Date: 07/12/2021
Date Signed: 07/13/2021 08:03:21 AM

COMPREHENSIVE INSPECTION
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:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Leila YeeTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual inspection on this date. LPA met with Leila Yee.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/or around the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Fire drill was conducted on 5/1/2021

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 2 staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during this visit. Advisories were given. .

Exit interview held and a report given with appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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