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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801520
Report Date: 01/05/2021
Date Signed: 01/05/2021 03:34:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAGNOLIAFACILITY NUMBER:
425801520
ADMINISTRATOR:DOROTHY BERGERFACILITY TYPE:
740
ADDRESS:4620 SONG LANETELEPHONE:
(805) 937-3332
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 10DATE:
01/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dorothy BergerTIME COMPLETED:
10:40 AM
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On 01/05/2021, at 10am, Licensing Program Analysts (LPA) Diaz spoke with Administrator, Dorothy Berger and LPA explained the purpose of today’s visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually.

The televisit was in response to an incident report from the facility regarding Staff 1 and Resident 1. LPA toured the facility and interviewed the Administrator. The Administrator stated that they will provide LPA Diaz with the written statements and additional interview documents regarding the incident.

Exit interview conducted, no citations issued, copy of report given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
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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