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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200865
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:43:24 PM

Document Has Been Signed on 12/17/2021 02:43 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MAGNOLIA GUEST HOME ANTIOCHFACILITY NUMBER:
079200865
ADMINISTRATOR:GEPULLE JR, GENE LFACILITY TYPE:
740
ADDRESS:2448 STANFORD WAYTELEPHONE:
(925) 642-0427
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
12/17/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Gene Gepulle, Administrator
Nazarene Lagadan, Caregiver		TIME COMPLETED:
03:15 PM
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On 12/17/21 at 2:35PM, Licensing Program Analyst (LPA) conducted an unannounced case management health & safety check while at the facility for another reason. Routine COVID-19 symptom checks were done by caregiver (S1) at the front entrance. LPA explained the purpose of the visit with administrator.

During the health and safety check, LPA toured facility with S1, including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed 5 residents resting comfortably inside their bedrooms while 2 masked staff on duty busy doing household chores at the facility.
Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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