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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202750
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:11:19 PM


Document Has Been Signed on 01/26/2024 12:11 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
Lookup Error,
, CA



FACILITY NAME:MAGDALENE RESIDENTIAL CARE IIFACILITY NUMBER:
435202750
ADMINISTRATOR:LITERATO-HILARIO, FEFACILITY TYPE:
740
ADDRESS:1107 E. HOMESTEAD ROADTELEPHONE:
(408) 564-0423
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Fe Literato-HilarioTIME COMPLETED:
12:15 PM
NARRATIVE
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On 1/26/24, Licensing Program Analyst (LPA) M. Medina made an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit, and allowed entrance by care staff. LPA met with Licensee, Fe Literator-Hilario. Fe also serves as facility Administrator Certificate #6029517740.

Currently, six (6) residents in care. All residents were present during inspection. Residents observed relaxing in the living room, watching television. Facility tour began in resident bedrooms. Rooms observed to have all required accommodations. All areas of the facility have sufficient lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed adequate food supply for the residents in care. LPA observed leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. Medications observed to be locked in small cabinet in kitchen.

Smoke Alarms and carbon monoxide detectors observed to be operational during time of inspection. Fire extinguisher has a service date of 4/03/2023. Last fire drill conducted on 12/15/2023 according to facility records. All cleaning supplies observed to be locked and secured under kitchen sink.

Outside areas toured. All exits open freely and observed to be free of obstruction. LPA observed side gate that exits to front of facility is not self latching. No hazards observed.

The following documents were submitted to San Bruno Regional Office in September 2023: LIC 308, LIC 400, LIC 500, LIC 503, LIC 610E, Administrator Certificate, Liability Insurance.

Exit interview conducted with Administrator. Deficiency cited on the attached 809-D. A copy of this report provided to Administrator for facility records.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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 2


Document Has Been Signed on 01/26/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: MAGDALENE RESIDENTIAL CARE II
FACILITY NUMBER: 435202750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 object which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Handyman repaired hinge on side gate to ensure that gate closes and is self latching. Deficiency cleared at time of inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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