<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:42:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240626090026
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:YOLANDA HARRELLFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH: Acting Administrator, Mike ChatmaTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff speak inappropriately to residents
Facility staff restrain resident's in a rough manner
Facility staff do not administer resident's medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman.
LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and residents and made observations during the course of the investigation.

Complaint alleges facility staff speak inappropriately to residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation.

Complaint alleges facility staff restrain resident's in a rough manner. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
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 21-AS-20240626090026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MAGNOLIA COURT
FACILITY NUMBER: 486803822
VISIT DATE: 07/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Complaint alleges, facility staff do not administer resident's medication as prescribed additionally indicating staff (S12) taking narcotics from the facility. Based on LPA spot review of medication supply and medication records, medications, narcotics and records for 3 out of 3 residents in memory care and 3 out of 3 residents in assisted living were found to be in order. During LPA observations during medication record keeping, administering and medication security protocols, LPA found that medtech staff (S2 & S11) appropriately handled medications and records. During a tour of the facility, LPA also found all medication storage carts to be secured and inaccessible to residents in care. Upon interviews with Director of Care and Resident Services (S9) & Resident Service Director (S10), medication destruction protocols were found to be properly implemented with no observed medications not properly disposed or destroyed. Lastly, upon review of S12's staff records LPA's did not find any corrective actions pertaining to allegation. Due to a lack of corroborating evidence, the allegation is unsubstantiated.

Allegations, facility staff speak inappropriately to residents, facility staff restrain resident's in a rough manner and facility staff do not administer resident's medication as prescribed are found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2