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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201049
Report Date: 06/22/2021
Date Signed: 06/30/2021 10:30:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MAGNOLIA INNFACILITY NUMBER:
435201049
ADMINISTRATOR:CAYTON, CYNTHIAFACILITY TYPE:
740
ADDRESS:176 SOUTH BERNARDO AVENUETELEPHONE:
(650) 968-8506
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:30CENSUS: 12DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Myrlin SadamaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Administrator (ADM) Myrlin Sadama. Later came the Prospective Licensee Neeru Verma.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance. LPA was temperature checked upon entry. LPA toured the facility with ADM.

The facility was observed to be in sanitary condition. Signs were posted to remind to practice social distancing. Hand sanitizers were available throughout the facility. All staff members were observed to be wearing masks. Tables in the dining rooms were at least 6 feet apart from each other. Some residents were having exercises in the activity room. Residents were estimated to be 6 feet apart. There were visitors in the visiting area located outside of the facility. Visitors observed to be wearing face masks and practicing social distancing.

LPA inspected the public restroom. The restroom observed to be adequately stocked with paper towels, hand soap, and covered trash bin. Hand washing sign was posted. LPA checked the PPE supply.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file. LPA reviewed the current mitigation plan with Prospective Licensee and ADM. No deficiency cited during visit. However, advisory notes were issued. See LIC 9102.

This report was reviewed with the Prospective Licensee and ADM. A copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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