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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397202998
Report Date: 05/28/2026
Date Signed: 05/28/2026 02:21:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2026 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260527081203
FACILITY NAME:J & R MAGSAYO HOME IIFACILITY NUMBER:
397202998
ADMINISTRATOR:MAGSAYO, RENDENTORFACILITY TYPE:
735
ADDRESS:544 WEST FIFTH STREETTELEPHONE:
(209) 937-9793
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Edwin ValdezTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff do not ensure that food service is of good quality
Staff does not ensure clients are given the opportunity to participate in the planning, preparation of activities
Staff does not ensure clients are accorded personal privacy
Staff does not ensure fire safety equipment is maintained in good repair
INVESTIGATION FINDINGS:
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On 05/28/2026, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to this facility to investigate the above allegations

During the visit, multiple health, safety, and compliance concerns were identified. Significant food storage and meal preparation issues were observed on 5/20/2026, including improperly dated pureed foods, items requiring freezer storage kept in the refrigerator, and numerous unlabeled foods stored in ziplock bags, foil, or plastic wrap. Cooked food was left inside the oven with clean cookware, and over half of the facility’s food supply consisted of frozen items. The facility operated on a rotating menu without documentation of resident involvement, and two residents reported dissatisfaction with food quality and limited fresh options. Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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 4
Control Number 27-AS-20260527081203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & R MAGSAYO HOME II
FACILITY NUMBER: 397202998
VISIT DATE: 05/28/2026
NARRATIVE
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Hazardous material concerns were noted after approximately ten cans of paint were found stored in the same room as the residents’ refrigerator. Medication administration and documentation also showed extensive deficiencies, including missing MAR signatures, undocumented dosage changes, handwritten alterations, lack of destruction records, incomplete prescription information, missing PRN documentation, and improperly filed medication records. . Bathroom access and privacy concerns were also documented. Although the home houses six residents and three staff, it has only two bathrooms, with one was remodeled to include wheelchair access.

The resident bathroom was overcrowded with two shower chairs stored inside the shower area, and its lock could be easily disengaged from the outside. Bedroom conditions were substandard, with overcrowded storage, belongings stacked or bagged along walls, a hole in the door of Bedroom #1, and one resident’s mattress placed directly on the floor without proper documentation or approval. Additional health and safety concerns were observed in the backyard, including a mop bucket filled with dirty water, a large, gated garden area restricted to staff-only use, and a padlocked shed containing residents’ personal property to which residents had no access. Finally, fire safety issues were identified when smoke detectors in Bedroom #1 and the hallway were found chirping, indicating low batteries or malfunction, and staff were unable to identify the company responsible for installation or maintenance.

Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D

Appeal rights provided. a copy of the report was read and given to staff, exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20260527081203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & R MAGSAYO HOME II
FACILITY NUMBER: 397202998
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2026
Section Cited
CCR
80020(a)
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80020(a) Fire clearance All facility's Shall secure and maintain a fire clearance approved by the city or county fire department, the district providing protection services, or the state Fire Marshal.
This requirement was not met as evidenced by:
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The facility will replace or repair the smoke detector by the POC date and summit the work order or receipt for the work completed to the department by the close of business on the poc date 5/29/26
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observation fire safety issues were identified when smoke detectors in Bedroom #1 and the hallway were found chirping, This presents an immediate health and safety risk to the clients in care.
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Type B
06/11/2026
Section Cited
CCR
80072(a)1-3
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a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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The facility has identified and made correction to the areas of concern and will send pictures or documentation to show compliance with the items identified in the report.
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This requirement was not met as evidenced by records reviewed and interviews conducted the facility has violated the personal rights of the residents in care.
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This information will be sent to the department by the close of business on 6/11/2026
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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260527081203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & R MAGSAYO HOME II
FACILITY NUMBER: 397202998
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2026
Section Cited
CCR
85076(a-d)
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(a) In addition to Section 80076, the following shall apply.

(b) The licensee shall meet the food service personnel requirements specified in Section 85065(e).
(c) The following requirements shall be met when serving food:
(1) Meals served on the premises shall be served in one or more dining rooms or similar areas in which the furniture, fixtures and equipment necessary for meal service are provided.

(A) Such dining areas shall be located near the kitchen so that food may be served quickly and easily.

(2) Tray service shall be provided in case of temporary need.
(d) The licensee shall meet the following food supply and storage requirements:(1) 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.(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (17.7 degrees C).

(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.
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The facility has addressed some of the items in the report, the facility will continue to review and make adjustments to the meal planning and over-all food service delivery.
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This requirement was not met as evidenced by observation, records reviewed and interviews conducted.observed on 5/20/2026, included improperly dated pureed foods, items requiring freezer storage kept in the refrigerator, and numerous unlabeled foods stored in zip lock bags, foil, or plastic wrap. Cooked food was left inside the oven with clean cook ware, and over half of the facility’s food supply consisted of frozen items. this is a potential health risk to residents in care.
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The facility will send a plan to the department by the close of business on 6/11/2026.
Type B
06/11/2026
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by
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The facility will complete an inservice training on 80075 to include all documentation requirements and medciation delivery.
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Medication administration and documentation also showed extensive deficiencies, including missing MAR signatures, undocumented dosage changes, handwritten alterations, lack of destruction records, incomplete prescription information, missing PRN documentation, and improperly filed medication records. This is a potential safety risk to residents in care
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The facility will send the training plan to the department by the close of business on 6/11/2026.
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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4