Magnolia Residence 1

Type of visit: Case Management - Other

Facility is closed no residents in care. LPA spoke with owner of facility. Licensee to surrender license, send a letter to confirm closing date and will submit annual fees if applicable.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications locked in each section of the facility. LPA did not reviewed resident and staff files, the facility is closings. No deficiencies were cited. Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Staff did not provide a proper eviction notice to resident in care

Licensing Program Analyst (LPA) Albert Johnson arrived to conduct a complaint investigation. Based on records reviewed and interviews with the staff the department finds the allegation to be substantiated the facility did not provide R1 with a legal document to met the regulatory requirements for a 30 day notice or a change of facility use. The information reviewed is dated 12/10/2024 and the facility is requesting R1 be out by 1/10/2025. This does not met the required 60 days written notice to evict a resident due to change of use of the facility. The information reviewed does not support the regulatory requirement to give a 30 day notice. Substantiated These are the standards for a 30 day notice. (1) Nonpayment of the rate for basic services within ten days of the due date. (2) Failure of the resident to comply with state or local law after receiving written notice of the alleged violation. (3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. R1 has not violated any of these reason to justify a notice. Citation given on the attached 9099 D page. The facility was advised regarding information required to met the regulatory requirements for the physician's report. (ambulatory status etc.... ) Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 27-AS-20241231092412

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a-i) · Plan of correction due date: Jan 10, 2025

87224(a) Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. This requirement is not met as evidenced by records reviewed and interviews conducted. R1 was not given due process for a 30 day notice nor was R1 given an approved by the department a 60 day notice.the state’s words, verbatim · CDSS document, Jan 3, 2025

Plan of correction: The Administrator /Licensee shall submit to the department the required information to evict or provide R1 with a reason for a 60 day notice to leave/vacate the facility. The required information shall be submitted to the department by the close of business on 1/10/2025 for approval to give the approved notice to R1.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced Post Licensing inspection on this date. LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. The licensee will remove all bedding items from the storage area and send a picture to confirm that the items have been removed. The licensee will have staff files available for review during each visit from licensing.(Advisories given). The Licensee will report deaths as defined in 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Exit interview held with Administrator/via phone and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 5, 2024

Type of visit: Required - 1 Year

On 7/15/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with MJ Samaniego and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications locked in each section of the facility. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. Fire drill was completed on 3/2024. The following forms need updating and submitted to CCLD by 07/20/2024: LIC 308 - Designation of Administrative Responsibility LIC 500 - Personnel Report LIC 610E - Emergency Disaster Plan First aid kit was checked and is complete. No deficiencies were cited. Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 15, 2024