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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607448
Report Date: 01/15/2025
Date Signed: 01/15/2025 11:09:57 AM

Document Has Been Signed on 01/15/2025 11:09 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MAGNOLIA TREE BOARD AND CARE HOME, THEFACILITY NUMBER:
300607448
ADMINISTRATOR/
DIRECTOR:		SABIO, MARILOUFACILITY TYPE:
740
ADDRESS:805 E WILSON AVETELEPHONE:
(714) 538-6046
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 4DATE:
01/15/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Marlenie CarazonTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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On 01/15/2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to continue the annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Marlenie Carazon. LPA Vanegas continued the annual inspection and observed the following.

LPA Vanegas observed client bedrooms to be clean and have enough space to move freely in them. Client bedrooms had all the required furnishings such as a lamp, chest drawers, a bed with linens in good repair meaning no strains or tears and the required closet space. LPA Vanegas tested water temperature to be between 98.5-105 degrees.

LPA Vanegas toured the outside of the facility and observed there to be an outdoor shaded seating area and a fenced pool. The fence measured to be 5 ft high. All exit routes are not obstructed by objects and is clear for an emergency evacuation. LPA Vanegas reviewed PNI with administrator (AD) Marilou Yanson and all balances were accurate and documented. LPA Vanegas reviewed resident medications and per LPA review medications are being administered per physicians orders.

LPA Vanegas observed all required postings to be posted on visible walls of the facility however PUB 475 was not the correct size and a technical violation was issued on today's date. LPA Vanegas observed staff files to not have documented training and a deficiency was issued on today's date.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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Document Has Been Signed on 01/15/2025 11:40 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/15/2025 11:33 AM


Created By: William Vanegas On 01/15/2025 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAGNOLIA TREE BOARD AND CARE HOME, THE
FACILITY NUMBER: 300607448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four staff files not containing the required documenation for annual training which poses a potential safety risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Administrator states that she will train staff and document it, and send proof of correction to LPA Vanegas by POC due date via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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