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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 05/20/2021
Date Signed: 05/20/2021 11:55:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:STOUDER, ROBINFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dennis RasmussenTIME COMPLETED:
12:10 PM
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At approximately 9:45 AM Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Dennis Rasmussen (DR) and Director of Resident Services, Savannah Arcy (SA). At the time of inspection there were 7 staff providing care and supervision for 64 residents.

LPA observed that proper signage was posted at the entrance and through out the facility to promote hand washing and social distancing. Upon entry, LPA was screened for COVID-19 symptoms using an oxygen meter and temperature gun. LPA then signed-in on the facility visitor log. A separate sign sheet and screening station for staff was at the entrance of the facility. Disposable mask and hand sanitizer were available. The facility was found to be clean and at a comfortable temperature of 67 degrees with all exits free from obstruction. There was one entry point for the facility.

LPA toured the facility with DR and SA. Residents temperatures are check daily and logged on a resident roster. Residents’ medications are stored on medication carts and in medication room. Facility has a 30-day supply of medication for residents. LPA observed that group activity and dinning tables were socially distanced. Per SA residents are encouraged to wear mask during group activities. Bathrooms were stocked with paper towel and hand washing supplies. All staff were wearing mask, and fit tested for N95 mask.

Facility has a supply of PPE stored in the hallway. Resident's emergency contact information has been updated and Emergency Personnel numbers are posted at the facility.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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