300607448-2-6-2026-22-AS-WVAS-DR32VY-20260206164443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300607448
Report Date: 02/06/2026
Date Signed: 02/06/2026 04:44:53 PM

Document Has Been Signed on 02/06/2026 04:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MAGNOLIA TREE BOARD AND CARE HOME, THE		FACILITY NUMBER:	300607448
ADMINISTRATOR/ DIRECTOR:	SABIO, MARILOU		FACILITY TYPE:	740
ADDRESS:	805 E WILSON AVE		TELEPHONE:	(714) 538-6046
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6		CENSUS: 4	DATE:	02/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Marilou Yanson (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	04:45 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	On today's date LPA William Vanegas conducted an unannounced visit for the purposes of completed an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by Administrator (AD) Marilou Yanson. LPA advised AD of the purpose of the inspection, and began a tour of the facility. LPA observed the following. The facility s a one storied home with five bedrooms two of which are staff rooms and three of witch are client rooms, three bathrooms one of which is a staff bathroom, and two of which are client bathrooms, and a two car detached garage. LPA observed for AD Marilou Yanson to have a valid Administrator Certificate that is set to expire on August 17, 2027. LPA observed all required postage to be posted at the entry way, and kitchen area of the facility. Including PUB 475, Ombudsmen sign, and resident rights. LPA Observed kitchen area to be clean and free of any mildew and debris. LPA observed there to be a gas stove, refrigerator, microwave, dishwasher, washer, and dryer. All were observed to be in good repair and tested operational. LPA observed there to be a two day supply of perishable food and a seven day supply of non-perishable food on hand. LPA observed a sufficient amount of emergency water and food on hand. LPA observed all resident rooms to be clean and in good repair. LPA observed resident rooms to have all required furnishings such as a bed, clean linens in good repair; meaning no strains or tares, a chest of drawers, a reading lamp, a chair, and enough storage space to store personal belongings. LPA observed no hazards in each resident room. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

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 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

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
	VISIT DATE: 02/06/2026

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 Observed all resident bathrooms to be clean and free of any mildew and debris. LPA observed resident bathrooms to have all required furnishings including a shower chair, slip resistant floor matts, and a shower chair. LPA observed toilets and faucets to be operational. LPA observed hot water temperature to be between 112.3 and 117.6 degrees.

LPA observed all smoke detectors and carbon monoxide detectors to be in good repair and tested operational. LPA observed all fire extinguishers to be fully charged and up to date. LPA observed first aid kit to have all required items such as a thermometer, bandages, adhesive tape, scissors, tweezers, and a first aid manual.

LPA observed outside of the facility to be clean and free of any hazards. No obstructions were observed to be outside or in the path of the emergency exits. There is a pool in the backyard, and it is fully fenced. The fence measures 5ft tall, and the gaps in between each bar is 4.5 inches. LPA observed side doors to be self latching and unlocked.

LPA reviewed four resident files and three staff files. Resident files had all required documents. However staff records did not have updated annual training available for LPA review. A deficiency was issued on today's date. LPA reviewed medication administration record and medications. Per LPA review medications are being documented correctly and being administered per physicians orders. LPA reviewed P&I with AD and all balances were accurate and they were all documented correctly.

Based on observations made during today's inspection deficiencies will be issued per tittle 22 division 6 of the California Code of Regulations. An exit interview was conducted with AD Marilou Yansen, and a copy of this report and appeal rights were provided to the facility. A copy of this report will be mailed to the facility as well.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/06/2026 04:44 PM - It Cannot Be Edited

Created By: William Vanegas On 02/06/2026 at 04:17 PM

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
, 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: 02/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three out of three staff not having updated anual training available for review which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/20/2026
	Plan of Correction
1 2 3 4	Administrator agrees to complete and document annual training for all staff on duty, and send proof of correction to LPA via email by P.O.C due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4