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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804188
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:30:19 PM


Document Has Been Signed on 11/09/2023 03:30 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 MANORFACILITY NUMBER:
496804188
ADMINISTRATOR:MATOS, ELIZABETHFACILITY TYPE:
740
ADDRESS:387 MAGNOLIA DRIVETELEPHONE:
(707) 217-3908
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:5CENSUS: 0DATE:
11/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Licensee Rafaela Lopez, Administrator, Elizabeth MatosTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived announced to conduct a Pre-Licensing Inspection and met with Applicants Rafaela Lopez and Elizabeth Matos.

Facility is a one story residence with four bedrooms (one shared, three private), two bathrooms, a laundry room and common areas. Resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 109 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked closet in the kitchen used for centrally stored medications. Cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a cabinet in the laundry room. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated October 30, 2023 that allows for up to four non-ambulatory and two bedridden residents. Facility has smoke detectors that were tested during the fire inspection. Facility does not have a carbon monoxide detector due to not having any gas appliances but agrees to obtain a detector to meet regulation.

LPA confirmed with Applicant that they are familiar with Guardian and has signed up fpr Provider Information Notices (PINs). Component III was conducted with Applicant.

LPA will notify Application Unit so application process may proceed.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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