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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 10/24/2025
Date Signed: 10/24/2025 04:59:42 PM

Substantiated


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
08/04/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250804125148
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: 79DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
03:14 PM
MET WITH:Jennifer Roldan, Business Office Manager for Kristine Soriano, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff are billing for services not rendered.
INVESTIGATION FINDINGS:
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On 10/24/2025,Licensing Program Analyst (LPA)Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation. LPA met with Jennifer Roldan, Business Office Manager for Kristine Soriano, Administrator to discuss.

The complaint alleges that staff are billing for services not rendered. The reporting party RP stated that Resident R1 received a billing increase for an increase in services in mid-July, 2025. The reporting party stated that R1 is not receiving the services being billed and paid for which includes: showers twice a week, incontinence care as required, and regular housekeeping to keep the room sanitary.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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 5
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
08/04/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250804125148

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: 79DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
03:14 PM
MET WITH:Kristine Soriano, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not safeguard resident belongings
INVESTIGATION FINDINGS:
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On 10/24/2025,Licensing Program Analyst (LPA)Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation. LPA met with Kristine Soriano, Administrator to discuss.
The complaint alleges that Facility staff did not safeguard residents’ belongings.

The complainant alleges that towards the end of 2024, there were multiple occasions when diapers were taken from R1’s room. Reporting party suspects that the staff may have been using diapers for other residents. LPA conducted an inspection of R1’s apartment on two occasions and found the door secured and R1’s incontinence supplies neatly stored in a closet.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250804125148
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: 10/24/2025
NARRATIVE
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Continued from 9099-A

There is no evidence of staff taking R1’s supplies and when LPA questioned other residents about missing supplies, 4 of 4 resident questioned stated that they had not found anything missing from their apartments. A resident (R2) did state that a staff member had asked to borrow some supplies once, but staff did ask and replenished the supplies later. R1’s supplies are not numbered or inventoried so there is no evidence to establish any misuse of R1’s incontinence supplies. Based on interviews of staff and residents and the lack of evidence to support that supplies were taken the allegation that Facility staff did not safeguard resident belongings is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Facility did not safeguard resident’s belongings is UNSUBSTANTIATED.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20250804125148
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: 10/24/2025
NARRATIVE
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(Continued from 9099)

The RP stated that R1 was found soiled on multiple occasions while visiting and staff needed to be called in to care for R1 and empty the trash. LPA reviewed documents and found that there was an assessment made on 6/6/2025 which states that R1 is a Level 4.This level provides a resident full assistance with bathing and all activities of daily living. Although the resident has the right to refuse services (which R1 did often, according to 4 of 4 staff interviews), the care plan in effect charged for the increased level of care and staff should have documented refusals and informed responsible party. On 8/7/25, LPA went to the room of R1 to conduct an inspection of the unit. LPA inspected R1’s room without R1’s presence and found the room to be neat and tidy but a definite smell of urine. LPA inspected bedroom and found sheets soiled with possible urine. Administrator and staff explained that R1 was not combative but yelled aggressively and repeatedly refused staff entry when staff tried to help. LPA noted that R1 was not in the room so staff could have changed the linens at that time. On 9/4/2025 LPA went to the room of R1 and found R1 in the unit in bed watching television. The room was neatly arranged but the room smelled (of feces). Both of these visits found R1 had not received the care/services that were listed in the service plan: the resident being clean and odor free. Additionally, the task list report dated 8/7/2025 stated that toileting tasks for caregivers, med techs and LVN/LPN will give reminders, and check bed each morning for soiled linens and if soiled change the bed and to report strong urine odors to DRS, LVN, Medtech and monitor for possible urinary tract infection (UTI). These tasks were not completed on the dates of LPA’s inspections. Based on LPA’s observations, and review of documents the allegation that staff are billing for services not rendered is Substantiated. The finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency a civil penalty assessment.

Continued on 9099-D

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

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250804125148
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
HSC
1569.657(a)
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Health and Safety Code1569.657provides:(a)For any rate increase due to change in the level of care......detailed explanation. This regulation was not met as evidenced by:
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LIcensee agrees to have staff review the care plan with resident R1's representative and provide a detailed explanation of the additional services to be provided to R1.
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Based on LPA's observations and review of records, the Licensee failed to provide the additional services that the new level of care and accompanying charges. This serves as an immediate health & safety and personal rights risk to residents in care.
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 A date of the care plan meeting to be provided to LPA by 10/27/25.A copy of the Care Plan signed by R1's representative will be submitted to LPA by 11/01/2025.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5