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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:42:37 PM

Document Has Been Signed on 08/29/2022 03:42 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MAGNOLIA CARE HOME 1FACILITY NUMBER:
392701190
ADMINISTRATOR:SOUMAHORO, MARIAM G.FACILITY TYPE:
740
ADDRESS:4727 SONGWOOD COURTTELEPHONE:
(209) 982-1457
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
08/29/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Virginia Ragasa TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Albert Johnson and Kesha Lewis arrived to conduct an Post licensing inspection. LPAs were greeted by Staff.

LPA toured the facility including but not limited to client bedrooms, 1 staff bedroom, 2 bathrooms, living room, dining room, kitchen, front yard and back yard. LPA observed during the tour the facility was clean with no odors. LPA observed 2 days perishable and 7 days’ Nonperishable food supply.

LPA observed fire extinguisher in the dining room. LPA observed smoke detectors located in client’s room, the hall way, and the dining room were operational. One carbon monoxide detector was observed in the hallway. Hot water temperature was tested and was 126 degrees Fahrenheit which is not within the required range of 105-120 degrees Fahrenheit.

LPA reviewed 2 clients and 1 staff files. All files were complete and all staff were fingerprint cleared and associated to the facility. First Aid and CPR are current.

Last fire drill was conducted on date unknown. LPA observed medication not locked and was accessible to clients. LPA cross referenced medications with the centrally stored medication record. During the tour of the facility toxins were observed in the residents room.

Citations issued on today’s visit per CA. Title 22 Regulations. Appeal rights and report left at the conculsion of the inspection
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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 3
Document Has Been Signed on 08/29/2022 03:42 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/29/2022 at 02:07 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited
CCR
80075(k)(1)

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80075(k)(1) Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees...
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The facility immediately lock/secure medications. The licensee shall conduct a staff in-service pertaining to medication storage and toxins (topic, instructor, date, time, names, signatures) and provide to LPA via email by 8/30/2022.
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Based on observation, the licensee failed to keep medications in a safe and locked place. LPA observed unlocked medication in the kitchen drawer and the refrigerator. This poses an immediate health and safety risk to residents in care.
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Type A
08/30/2022
Section Cited
CCR80088(e)(1)

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Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F.
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Facility shall adjusted hot water temperature to not less than 105 degrees F and not more than 120 degrees F. LPA requested hot water temperature logs over the course of the next 7 days to clear the cited deficiency
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This requirement is not met as evidenced by: Hot water temperature was measured at 126.5' This poses an immediate health and safety risk to residents in care.
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Hot water logs are to provide proof that hot water is being maintained within the regulatory requirements.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/29/2022 03:42 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/29/2022 at 02:21 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited
CCR
87705(l)(8)

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87705 (l)(8)-Care of persons with dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.-
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Administrator shall conduct a fire drill and send proof of that a fire drill was conducted to CCL by the POC due date.
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There was no documentation that a recent fire drill had been conducted.
This poses an immediate health and safety risk
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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