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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200865
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:39:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210426080728
FACILITY NAME:MAGNOLIA GUEST HOME ANTIOCHFACILITY NUMBER:
079200865
ADMINISTRATOR:GEPULLE JR, GENE LFACILITY TYPE:
740
ADDRESS:2448 STANFORD WAYTELEPHONE:
(925) 642-0427
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gene Gepulle, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Resident is being illegally evicted
INVESTIGATION FINDINGS:
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On 12/17/21 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the finding of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Resident is being illegally evicted
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, administrator sent a written 30 day notice of eviction to resident (R1) dated 04/09/21 which stated R1 is being evicted due to failure to submit the requested annual physician’s report, be examined by a doctor due to her medical & psychological condition requiring a higher level of care which the facility cannot provide. However, facts alleged in the notice fail to support any of the authorized reasons for termination of tenancy. Facility staff could not produce a written reappraisal report showing that R1 requires a higher level of care based on a current physician’s report.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20210426080728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAGNOLIA GUEST HOME ANTIOCH
FACILITY NUMBER: 079200865
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
87224(a)(4)
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Eviction Procedures (a)(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.
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Administrator corrected deficiency on 04/29/21. The 30-day notice of eviction for R1 was rescinded by administrator, who continues to work with R1’s Ombudsman and case manager in addressing her medical and care needs.
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This requirement was not met as evidenced by the absence of R1's reappraisal from a current physician's report which posed a potential health & safety risk to resident in care
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2