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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600154
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:39:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/08/2024 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MAGNOLIA OF MILLBRAEFACILITY NUMBER:
415600154
ADMINISTRATOR:LOLA BORREGOFACILITY TYPE:
740
ADDRESS:201 CHADBOURNE AVENUETELEPHONE:
(650) 697-7700
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:180CENSUS: 104DATE:
05/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Charito Amoranto and Lola Borrego TIME COMPLETED:
12:45 PM
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To complete annual inspection of 4/12/24, LPA Jeung reviewed staff records--including training--and reviewed clients' admission agreements. In addition, medication discrepancies pertaining to supplements observed on 4/12/24 have been resolved for client #3.

No deficiencies of the California Code of Regulations, Title 22 are observed. Facility is operating in substantial compliance.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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