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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 07/22/2025
Date Signed: 07/22/2025 03:02:13 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
04/07/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250407085527
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:MOSES, CANDICEFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 80DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff do not ensure adequate supervision is provided to residents in care
Staff do not ensure care needs of residents are being met
Staff do not ensure medications are dispensed as prescribed
Licensee allows unqualified staff to dispense medication
INVESTIGATION FINDINGS:
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On 7/22/2025 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue an investigation and deliver findings regarding the above allegations. LPA met with Administrator Candice Moses and Memory Care Director Gina Lapid.

The complaint alleges Staff do not ensure adequate supervision is provided to residents in care. LPA observed that during visits on 3/11/2025 (11AM - 4PM), 4/1/2025 (10AM - 4PM), 4/7/2025 (3:20-4:50 PM), 5/29/2025 (10:25AM - 4:55PM), 7/17/2025 (10AM - 2:45PM) and 7/22/2025 (12:55 - 2:00PM) there appeared to be adequate supervision during the time of visit, with a majority of residents out of their rooms socializing in the common rooms; typically 20-22 of 28 residents on the days observed with one caregiver circulating in the common areas and two caregivers and a med tech providing care and medications to residents in their rooms. Based on LPA's observations and staff schedules the allegation that Staff do not ensure adequate supervision is provided to residents in care is unsubstantiated.
Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.
(Continued on 9099-C)

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

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
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 3
Control Number 21-AS-20250407085527
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: 07/22/2025
NARRATIVE
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(Continued from 9099)

The complaint alleges that Staff do not ensure care needs of residents are being met. The complainant states that there are only 2 caregivers assigned. Regulations for CCL do not require a ratio between care staff and residents. LPA reviewed facility records and found 3 care staff and one medtech scheduled to work in the memory care unit for the AM and PM shift. LPA observed the facility on multiple occasions (3/11/25, 4/1/25, 4/7/25,5/29/2025, 7/17/25, 7/22/2025) and found the facility to be clean and the residents to be clean and dressed appropriately. LPA observed lunches being served and activities (manicures, Trivia, Bingo, Uno, Art/Coloring) and found residents to be assisted as needed. LPA reviewed a sample of 5 of 28 residents’ care/service plans and found residents care plans were recently updated to meet the residents’ needs. According to staff (S1), incontinence care is not charted but staff have a schedule to ensure residents are receiving two-hour checks and continence care. In addition, according to statements by staff member (S1) residents who are in their rooms receive additional safety and continence/re-positioning care (like for those receiving hospice services). Based on observation of residents, sampling of resident weight records and resident interviews (4 of 28 residents in Memory Care) the allegation that Staff do not ensure care needs of residents are being met is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.

The complaint alleges Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed. The complainant states various caregivers are assigned medtech duties who are not qualified and they are dishonest about distribution of meds. LPA reviewed staff training documentation which shows that staff employed as medication technicians receive training and are tested to verify their knowledge. Also, licensed LVNs and RNs are employed to supervise care and administer insulin injections to those residents requiring per physician’s orders. LPA reviewed medication records of residents receiving insulin and found that the insulin was administered per doctor’s instructions by a licensed professional/LVN/RN.

(Continued on 9099-C2)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250407085527
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: 07/22/2025
NARRATIVE
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(Continued from 9099-C)

In addition, Medication Administration Records (MARs) were inspected and found to be completed. LPA performed an inspection of random medications pulled from the medication room in Memory Care and 5 out of 5 were accurate. Based on the review of MARs, medications, training records and inspection of professional licenses the allegation that Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated. Although the allegations may have happened there is not a preponderance of evidence to verify the allegations therefore, the allegations that unqualified staff are allowed to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3