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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397202998
Report Date: 08/01/2023
Date Signed: 08/09/2023 11:18:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230627084955
FACILITY NAME:J & R MAGSAYO HOME IIFACILITY NUMBER:
397202998
ADMINISTRATOR:MAGSAYO, RENDENTORFACILITY TYPE:
735
ADDRESS:544 WEST FIFTH STREETTELEPHONE:
(209) 598-6098
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edwin ValdezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Home is storing a large amount of consumers’ incontinence supplies outside on the patio. Potential fire hazard
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Albert Johnson visited the facility today to deliver findings for the complaint investigation.

Based on observation and photos taken the facility is storing large amount of incontinence supplies which is a potential fire hazard. The facility has recived extra incontinence suppiles and did not have room to store these items in a safe location.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 3
Control Number 27-AS-20230627084955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: J & R MAGSAYO HOME II
FACILITY NUMBER: 397202998
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
80087(C)
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80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
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The facility shall clear off the back porch area of the stored incontinence supplies, boxes and any othe items that maybe a potential hazard by 8/15/2023.
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This requirement is not met as evidencied by observation and photos. The back porch area has a large amount of consumers’ incontinence supplies. This is a potential safety hazard.
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The Licensee will provide the department with a photo of the cleared area by close of business on 8/15/2023.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3