<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606109
Report Date: 03/04/2025
Date Signed: 03/05/2025 11:44:47 AM

Document Has Been Signed on 03/05/2025 11:44 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/
DIRECTOR:		JEANETH T. CRISTOBALFACILITY TYPE:
740
ADDRESS:20648 BLACKHAWK ST.TELEPHONE:
(818) 701-0016
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 2DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jeaneth Cristobal, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:15am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and LPA explained the reason for the visit.

At 11:20am LPA conducted a tour of the physical plant and observed the following:

Upon entry, LPA observed a locked closet and was informed that all residents medications and files are kept in there. Facility is licensed for capacity of six (6) Non-Ambulatory residents. There are four (4) bedrooms designated for clients’ use, of which two (2) bedrooms are private and two (2) bedrooms are shared. Bedrooms are appropriately furnished and have appropriate lighting. Facility has awake staff at night. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. The hot water temperature measured at 120.0°F. Facility maintains a temperature of 72°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher is located in the kitchen and was last serviced on 03/18/2024. Laundry is located in the garage. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. All chemicals, detergents and medications are kept in the garage and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 11:40am and observed to be functional. At 11:50am, LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around. You will need a key to gain entry to the swimming pool as it is kept locked at all times.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: 03/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed the importance of maintaining the care and supervision to meet the needs of residents.. Between 11:50am to 12:30am, LPA reviewed records of two (2) residents and two (2) staff. Client and staff records appeared to be complete and updated. Annual fee is paid in full. LPA observed Administrator certificated renewed on 07/26/2024 with an expiration date of 07/25/2026. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2