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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 11/12/2024
Date Signed: 11/12/2024 01:24:38 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
08/13/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240813153600
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: 80DATE:
11/12/2024
UNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
01:24 PM
ALLEGATION(S):
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9
Staff not meeting residents care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced and conducted a complaint investigation regarding the allegation listed above. LPA met with Candice Moses, Administrator.

The complaint alleges that staff are not meeting resident’s care needs. During the investigation LPA reviewed records, made observations and conducted interviews. LPA's record review found that resident R1 was hospitalized from 7/21/24 – 7/27/24. A review of records during this time did not reveal any concerns regarding R1’s care. On 8/13/2024 R1 was sent to ER and at that time there were concerns raised regarding hygiene care.

Continued on 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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-20240813153600
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: 11/12/2024
NARRATIVE
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Continued from 9099....

LPA reviewed care notes for R1 and found that staff attempted to give R1 regular continence care, showers, or bed baths and to reposition resident as per doctor’s orders. Care notes indicate that R1 could be combative or refuse care and additional staff was utilized to help facilitate care. Notes from home health reviewed do not show any indications facility failed to meet resident’s care needs. Although the allegation could have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2