486803822-5-29-2025-21-AS-JNAA-DH5VZQ-20250529165306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 05/29/2025
Date Signed: 05/29/2025 04:53:17 PM

Document Has Been Signed on 05/29/2025 04:53 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MAGNOLIA COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR/ DIRECTOR:	MOSES, CANDICE		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY: 146		CENSUS: 82	DATE:	05/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:26 AM
MET WITH:	Candice Moses, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

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	Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a 1-Year Annual Inspection. LPA was welcomed by receptionist and asked to sign the visitor's book. LPA met with Candice Moses, Administrator. There were 82 residents in care at the time of inspection. The facility provides both assisted living and memory care. LPA requested personnel and resident records for review. LPA found 5 of 5 resident records and 5 of 5 personnel records well-organized and complete. LPA then toured facility with Director of Resident Care and Director of Memory Care. 10 resident rooms were inspected and found to be clean, orderly, and furnished as required by Title 22. The common areas of the Memory Care Unit were well-lit and staff were interacting with residents. There is also a secure area for residents in Memory Care to enjoy a walk or relax outside. Assisted Living apartments were found to be furnished appropriately, with bathrooms having the required grab bars and non-slip mats. Water temperature was within regulation. The ambient temperature of the building was between 72-74 F at the time of inspection. The kitchen was clean and well-stocked with an ample supply of perishable and non-perishable foods, as required per Title 22. Fire alarms had been inspected on 03/24/2025 and found to be operational. The facility conducted fire drills for all three shifts in April, 2025. . Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/29/2025

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Continued from 809.....

Stair chairs were installed at the top of each stairway as required. The medication rooms for Assisted Living and Memory Care use an E-Mar system and had the Centrally Stored Medication List available for review. Medications are live-poured and med carts are used for storage and delivery. Facility has a 30-day supply of medication for residents. Nurses are on site daily to help with

medication management and resident assessment.

LPA inspected the facility's outdoor areas and found them to be free of debris and ready for residents to enjoy.

Administrator's certificate #7008136740 is current. All required postings were present.

The following documents are requested for submission by 6/5/2025:
Current Lease Agreement or Control of Property
Proof of Liability Insurance
Updated Disaster Plan

Discussion was had regarding acceptable courses for First Aid/CPR certification.

No citations issued.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC809 (FAS) - (06/04)

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