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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600154
Report Date: 07/14/2020
Date Signed: 07/14/2020 02:53:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MAGNOLIA OF MILLBRAEFACILITY NUMBER:
415600154
ADMINISTRATOR:SORENSEN, PATRICIAFACILITY TYPE:
740
ADDRESS:201 CHADBOURNE AVENUETELEPHONE:
(650) 697-7700
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:180CENSUS: 130DATE:
07/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Lola Borrego, AdministratorTIME COMPLETED:
02:30 PM
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LPA Raygoza conducted a case management Tele-visit via Face time and met with Administrator, Lola Borrego. A pre-complaint was submitted to CCL Office regarding R1 not being groomed due to shelter in place closure of Beauty Parlor.

Reporting party concerns were in regards to R1 not being groomed. R1's hair knot and nails not being trimmed is a hygiene concern. As a result, Administrator will submit a plan of care for R1 and residents' grooming plans.

No deficiency cited.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020
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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