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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701190
Report Date: 07/25/2025
Date Signed: 07/25/2025 05:06:19 PM

Document Has Been Signed on 07/25/2025 05:06 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MAGNOLIA CARE HOME 1FACILITY NUMBER:
392701190
ADMINISTRATOR/
DIRECTOR:		SOUMAHORO, MARIAM G.FACILITY TYPE:
740
ADDRESS:4727 SONGWOOD COURTTELEPHONE:
(209) 982-1457
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
07/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:08 PM
MET WITH:GertrudeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct an annual visit on 7/25/2025 at 12:00pm, The LPA asked the staff gertrude to call the administrator so the purpose of the visit could be explained. Magnolia care home 1 is a 6 bed facility for the elderly with 5 residents in the current census. 2 ambulatory, 3 nonambulatory. 1 has dementia. 2 are on hospice. 4 have diabedes(controlled via PO medication).

Physical Plant was inspected, including but not limited to the kitchen, common areas, client bedrooms, client bathrooms, exteriors, and evacuation routes. The facility is clean, and traffic areas are well lit and unobstructed. the kitchen has adequate lockable storage for sharps and toxics, there is 2 days of perishible/7 days of nonperishable foods. MARs for each of the residents were checked; in 1 of 5 records a psychotropic medication(trazadone) was not documented as given when it was for many days this month. The common areas are clean and have enough space for activities. the bathrooms have hardware in good repair, temperature was measured at 118*F. LPA observed hygine related toxics(hand soaps/shampoos/conditioners/hairsprays) within access to ambulatory dementia client. Client is on 1 to 1 supervison, it is unlikely she would use the bathroom by herself, however she does wander at night. The Licensee is going to store the offensive chemicals locked. The exterior screens are in good repair, plenty of space for activies, no tripping hazards. evacuation route gate is in good repair. Fire extinguisher was last checked 5/19/25. Posters in cluding the facility sketch, administrator cirtificate, facility license, federal work requirements, personal rights, and the ombudsman information are all present and of the correct dimension.

Continued on C Page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2025
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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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190
VISIT DATE: 07/25/2025
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5 of 5 Client records were reviewed, the files included but were not limited to the signed admission agreements, physicicians reports, hospice care plans, preadmission apprasials, and emergency contact information. Files were found to be present and up to date. Personal property for 1 of the clients was labled "cloths" with no itemization, personal property for 1 of the clients was missing signtures and numbers regarding some expensive property(television, cellphone, ect). Licensee is going to get the Personal property reinventoried and get signatures from the clients or thier representatives.

3 of 3 Staff records were reviewed, including but not limited to criminal background checks, fingerprinting, cprt/first aid training, and annual continuing trainings. 2 staff do not have an up to date cpr/first aid training on file, 3 staff do not have continuing training with regard to the specific topics within dementia care or the general topics in RCFE care. There is staff on duty with a up to date cpr/first aid at the time of this report. Licensee reports at least 1 staff having an up to date cpr/first aid training that has not yet been added to the file. Licensee provided the training would be completed as soon as possible and continued annually into the future.

Administrator records were reviewed, including but not limited to the program design, sample admission agreement, liability insurance, evacuation plan, administrator certificate, facility license, shift logs, staff roster, and client roster. Documents are present and up to date.

Client interviews, 2 clients were interviewed. concerns related to the high salt content of the meals were raised.

Staff interviews, 2 staff were interviewed. staff are unfamilar with resident rights and abuse reporting requirements.

Per title 22, Citations, Technical Violations, and Technical Advisories were given as a result of this visit.

LPA is requesting a updated 610E, sent to the LPA(noel.wolfpetersen@dss.ca.gov) by 8/1/25
An exit interview was conducted, the copy of the report was read and given to the staff.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2025 05:06 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 07/25/2025 at 04:47 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 20+ containers of soaps/shampoos/detergents/hair products which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Put the chemicals away in lockable storage, no poc requred.
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 3 out of 3 records which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee will complete required trainings for topics in dementia care for the staff, send the LPA an signed afidavit that the trainings were completed with a signature by staff, topic titles, and hours completed per training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2025


LIC809 (FAS) - (06/04)
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