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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:15:43 PM


Document Has Been Signed on 06/27/2024 04:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:YOLANDA HARRELLFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 71DATE:
06/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Michael Chatman, Acting Executive Director TIME COMPLETED:
12:45 PM
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On 6/27/2024, Licensing Program Analysts (LPA) Mutialu arrived unannounced for the purpose of a Case Management- Health and Safety Check regarding fire incident on 06/26/2024. LPA toured the facility and interviewed staff/clients Facility to provide updated Smoking Policy, process on preventing fires, how this process will be overseen, and Fire Marshall Report from 06/26/2024 to CCLD by 07/06/2024.





No deficiencies cited.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024
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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