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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801520
Report Date: 03/19/2021
Date Signed: 03/19/2021 03:52:32 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: 11DATE:
03/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Dorothy BergerTIME COMPLETED:
03:50 PM
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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.

It was alleged that on 12/25/2020, Staff 1 (S1) observed Staff 2 (S2) hit Resident 1 (R1) in the head and on the legs. S1 did not report the incident to the Administrator until 12/30/2020. The Administrator sent an incident report and SOC341 to CCL on 12/31/2020.

LPA reviewed written statements from S1 and S2. S2 denied ever hitting a resident and stated she gets along with all residents and staff in the facility. S1 did not respond to LPA’s multiple interview attempts. Additional staff interviewed stated they have never observed any abuse occurring in the facility. Additional staff interviewed stated that S2 gets along with everyone in the facility and works well with others. Additional staff interviewed stated S2 has not displayed any signs of aggression towards the residents. Administrator stated both S1 and S2 have been good caregivers and are responsible. LPA interviewed R1, but R1 did not respond coherently to the questions asked. LPA interviewed a credible witness who stated they have not observed any abuse in the facility.

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: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
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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