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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801520
Report Date: 02/02/2022
Date Signed: 02/02/2022 02:24:16 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: 12DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Mathew Kenny VittyTIME COMPLETED:
02:30 PM
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On 02/02/22 at 12:50 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA spoke with Licensee/Owner Margie Halsell and obtain authorization to conduct inspection with Staff (S1) Mathew Kenny Vitty. LPA met with S1 and explained the purpose of the visit.

At 1:20 p.m., LPA discussed items in the Infection Control Module and noted that facility did not post California Department of Social Services (CDSS) Provider Information Notices (PINs). Infection Control module was addressed with S1 to satisfaction.

LPA conducted exit interview with S1 and emailed a copy of today's report to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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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