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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708852
Report Date: 07/12/2021
Date Signed: 07/15/2021 09:00:54 AM

Document Has Been Signed on 07/15/2021 09:00 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,
, CA
FACILITY NAME:MAGALLANES REST HOMEFACILITY NUMBER:
270708852
ADMINISTRATOR:MAGALLANES, LYDIAFACILITY TYPE:
740
ADDRESS:193 LILLIAN PLACETELEPHONE:
(831) 917-3584
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 6CENSUS: 0DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Lydia MagallanesTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Lydia Magallanes Administrator. There are no residents in care at this time.

LPA toured the facility inside and out to include the entry, bedrooms and bathroom, kitchen, dining room, living room, laundry/garage area and exterior. All fire exit routes were free and clear of obstructions. Medications to be stored in locked cabinet in the dining room. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathroom observed to be supplied with hygiene products. Hand washing sign were posted in bathroom. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Lydia Magallanes Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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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