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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606109
Report Date: 03/17/2022
Date Signed: 03/17/2022 11:49:08 AM

Document Has Been Signed on 03/17/2022 11:49 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAGNOLIA MANORFACILITY NUMBER:
197606109
ADMINISTRATOR:JEANETH T. CRISTOBALFACILITY TYPE:
740
ADDRESS:20648 BLACKHAWK ST.TELEPHONE:
(818) 701-0016
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 3DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Jeaneth CristobalTIME COMPLETED:
12:00 PM
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At 9:35 a.m Licensing Program Analyst (LPA) Joscelyn Martinez conducted an announced annual inspection. Upon arrival LPA met with Administrator Jeaneth Cristobal. A physical tour of the facility was conducted and the following was observed: Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, Administrator took LPA's temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested between 10:12 a.m and 10:21 a.m. and appear to be functional. Fire extinguisher has a purchase date of 03/17/2022. Common Areas: All common areas were observed to be clean and properly furnished. There is current construction going on in the kitchen. Counter tops are being upgraded and floors are being replaced. Counter tops should be completed by the end of today and flooring is scheduled to be completed in two weeks. Facility maintains a comfortable temperature of 71.0 F. Residents Rooms: There are six (6) rooms which four (4) are designated for resident use. Administrator and one additional staff live in the facility on the second floor. The second floor of the house remains inaccessible to residents. All of the residents’ bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Trash cans in residents’ bedrooms have tight fitting lids.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAGNOLIA MANOR
FACILITY NUMBER: 197606109
VISIT DATE: 03/17/2022
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Bathrooms: There are 3 bathrooms which of 2 are designated for resident use. LPA observed all bathrooms to have grab bars and non-skid mats. At 10:52 p.m. the hot water was tested and measured at 107.0 F. Garage: There is an attached garage that remains locked and is being used for additional storage/laundry area. Chemicals are locked inside the garage. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a body of water that remains locked and is inaccessible to residents.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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