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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701190
Report Date: 09/03/2025
Date Signed: 09/03/2025 01:38:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20250624162907
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:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:gertrude mwaashidzanaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in inappropriate behaviors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unanounced to deliver findings of a complaint with the above allegation, LPA met with staff gertrude mwaashidzana and administrator Miriam by phone.

The allegation was investigated by record review, interview, and observation. The facility has a resident with wandering and dementia, the record review of the staff schedule detailing the noc shifts 2-hour checks on the resident was not filled out on two seperate occasions the LPA came by to review it. In interviews two of the 3 staff are saying there was an incident caused by this resident wandering into other clients rooms at night. LPA observed the resident wander around the facility, without redirection from the staff to avoid entering the room of the client who does not want to share that private space. Based on LPAs observations and interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D.

Appeal rights and a copy of the report were read and provided to the staff. Exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20250624162907

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:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:gertrude mwaashidzanaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff screamed at resident
Staff are mismanaging resident's medication
Staff inappropriately opened resident's mail
Staff did not ensure resident received a copy of her admissions agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unanounced to deliver findings of a complaint with the above allegation, LPA met with staff gertrude mwaashidzana and administrator Miriam by phone.

Above allegations were investigated by record review, interview, and observation. LPA did not observe staff raise their voice to a resident in three seperate visits, although the context of the yelling was an extrodinary circumstance. No staff is coming forward about an observed interaction that could be characterized by yelling. The mismanaged medication; 2 of 3 staff are saying over the counter medication that was ordered by the resident may have been withheld/destroyed in the context of concerns of not being perscribed/possible interactions with perscriptions. While the facility would be right to keep potentially dangerous medications out of the residents possession, it is still personal property that should be doucumented and accounted for and not destroyed or lost by the facility. At this time however, neither party to the complaint is able to produce a receipt of the medication or knows where the medication is now or if it was destroyed.

Continued on C page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250624162907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/03/2025
NARRATIVE
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The opening of the mail was done in the context of the regular duties of the staff to assist in the clients medication needs, packages from the pharmacy were opened, regular mail was not. LPA observed resident did have the admission agreement in thier possession, facility and family member present at the time of the signing report it was given to the resident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Appeal rights and a copy of the report were read and provided to the staff. Exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250624162907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 personal rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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nightly Logs from awake staff showing observations from the supervision at night, at minimum 2 hour checks to know if the residents are agitated and in need of intervention, should be sent to the LPA end of day tomorrow, 9/4/25 and then again at the end of the month 9/30/25.
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record review of staff duty list not documenting wandering resident is checked at night. 2 staff interviews indicating that an inccident occured where wandering resident entered the room of another resident at night, this consitiutes a personal rights risk to clients in care.
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the practice should continue as long as dementia residents with wandering behavior are 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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4