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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200865
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:32:06 PM

Document Has Been Signed on 02/21/2023 03:32 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:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nazarene Lagadan, StaffTIME COMPLETED:
04:50 PM
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On 02/21/23 at 3:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator on the phone who authorized staff (S1) to act on his behalf and sign the reports. LPA observed 2 staff wearing face masks during visit with 5 residents relaxing inside their bedrooms.

LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 73 deg F. Facility has a mitigation plan in place and maintains records of routine screening for residents and staff. The infection control leader is the administrator.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 2/22/23:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan including infection control plans
· Evidence of Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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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