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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201415
Report Date: 04/09/2025
Date Signed: 04/09/2025 09:53:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/30/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241230120712
FACILITY NAME:MAGNOLIA GARDEN ASSISTED LIVINGFACILITY NUMBER:
079201415
ADMINISTRATOR:OLIVA, JOSEPH ANTHONYFACILITY TYPE:
740
ADDRESS:205 EL PINTO ROADTELEPHONE:
(510) 364-5158
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:36CENSUS: 22DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Backup Administrator, Heidi YrreverreTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff did not respond to calls for assistance.
Facility not adequately staffed to meet the residents needs.
INVESTIGATION FINDINGS:
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On 4/09/2025 at 8:40 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver for the above allegation. LPA met with Backup Administrator, Heidi Yrreverre and explained the purpose of the visit.

During the investigation the LPA obtained copies of the staff schedule, resident roster, LIC 500, and emergency disaster plan. LPA also interviewed the Licensee durring the initial visit.

report continues on LIC909-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 3
Control Number 15-AS-20241230120712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MAGNOLIA GARDEN ASSISTED LIVING
FACILITY NUMBER: 079201415
VISIT DATE: 04/09/2025
NARRATIVE
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On 1/9/2025 when LPA interviewed the Licensee and they stated that there were staff on the day of the incident but that the staff did not acknowledge the Fire Department because they were "Busy" with other clients. Licensee states that they were called and notified by the fire department that the fire alarm was tripped and that they could not locate staff. Licensee also states that they(staff) did not evacuate and follow the disaster plan because they knew that the fire alarm going off was a false alarm because a visitor was vaping in the bathroom. Licensee acknowledges that the staff should have met with the fire department and states that staff had an in service about what to do next time. Residents were observed in the loby unsupervised the day of the incident needing assistance. Licensee states that the staff were nervous to speak with the fire department and that staff did not come to the loby. On 1/9/2025 LPA observed that they were no staff available at the front loby and LPA had to locate staff to get assistance upon arrival. Based on observation and interviews the allegations, "Facility staff did not respond to calls for assistance." and "Facility not adequately staffed to meet the residents needs" are substantiated

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241230120712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MAGNOLIA GARDEN ASSISTED LIVING
FACILITY NUMBER: 079201415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary ... facility require such additional staff for the provision of adequate services.

This requirement was not met as evidence by:
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Facility conducted an in service as to what to do in an emergency and has also agreed to hire additional staff so that there are at least 5 care staff on duty at all times with at least 1 staff always available at the front desk. Facility agrees to send an updated LIC 500 to CCLD when additional staff are hired.
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Based on observation and interview, the licensee did not comply with the section cited above by not having competent adequete staffing which poses a potential safety and personal rights risk to persons in care.
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Type B
04/30/2025
Section Cited
HSC
1569.269(a)(6)
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(a) Residents...shall have all of the following rights: (6) To care, ...delivered by staff that... meet their needs.

This requirement was not met as evidence by
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Facility agreed to hire additional staff so that there are at least 5 care staff on duty at all times with at least 1 staff always available at the front desk. Facility agrees to send an updated LIC 500 to CCLD when additional staff are hired.
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Based on observation and interview, the licensee did not comply with the section cited above by not having staffing available to repond to needs which poses a potential safety and personal rights risk to persons 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3