<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801520
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:46:39 PM


Document Has Been Signed on 11/21/2022 03:46 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
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:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Susie Halsell, Business Manager, Margie Halsell, Licensee, and Dorothy Berger, AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/21/22 at 2:08 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Susie Halsell, Business Manager, and explained the purpose of the visit. At 2:50 pm and 3:00 pm, Margie Halsell, Licensee/Owner, and Dorothy Berger, Administrator arrived, and LPA explained the purpose of the visit.

LPA toured the facility with the business manager and observed the following: The facility has infection control signage throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located in the kitchen and bedroom hallway. The extinguishers are fully charged and were inspected on 12/9/21. The facility has a fountain at the entrance which is filled with rocks. LPA observed six dishes/bowls in the refrigerator and one storage container on the shelf in the kitchen which were not labeled and dated. There were several other covered containers which were dated/labeled in the refrigerators, however, the facility is not in full compliance and therefore is receiving a technical advisory. The facility will conduct training with staff to ensure future compliance in full. Administrator will send a training sign-in sheet with staff signatures and date(s) to CCL by 11/28/22.

At 3:02 pm, LPA conducted the Infection Control mitigation module with the licensee, administrator, and business manager. No deficiencies cited.

Exit interview conducted and the report emailed to the administrator and business manager.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1