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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:00:16 PM

Document Has Been Signed on 10/28/2021 12:00 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:LEHMAN, SIOBHANFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 146CENSUS: 81DATE:
10/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amber EbertTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst arrived unannounced for the purpose of following up on a reported incident involving an elopement by a resident whose physician has ordered that the resident not leave the facility unassisted. LPA spoke with staff and reviewed documents and concluded that there was a lack of supervision which resulted in the elopement. Vacaville Police Department returned the resident to the facility, unharmed, approximately 30 to 40 minutes later.



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The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Civil Penalty issued in the amount of $500.00 for Lack of Supervision.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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Document Has Been Signed on 10/28/2021 12:00 PM - It Cannot Be Edited


Created By: David Leibert On 10/28/2021 at 11:34 AM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAGNOLIA COURT
FACILITY NUMBER: 486803822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2021
Section Cited
CCR
87464(f)(1)

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87646 Basic Services. Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

Based upon records reviewed and statements made, this requirement has not been meet as
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Administration to submit report to CCL addressing how the incident occurred and what steps will be put in place going forward to insure that memory care residents are provided adequate supervision in order to avoid potential elopements by residents in care. Submit by POC date in order to cure the deficiency.
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evidenced by: On or about 08/22/2021, a resident eloped from the memory care unit unaccompanied by staff and remained away until returned by Vacaville Police 30 to 40 minutes later. This posed an immediate risk to safety of resident. $500 Civil Penalty issued for lack of supervision.
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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.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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