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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 03/27/2026
Date Signed: 03/27/2026 04:35:11 PM

Document Has Been Signed on 03/27/2026 04:35 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 COURTFACILITY NUMBER:
486803822
ADMINISTRATOR/
DIRECTOR:		SORIANO, KRISTINEFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 146CENSUS: 92DATE:
03/27/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Kristine Soriano/Hiquiana, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management inspection and met with Executive Director (ED) Kristine Soriano/Hiquiana. The purpose of today's inspection was to follow up on self reported incidents submitted to Community Care Licensing (CCL) on 03/24/2026. LPA made observations, conducted interviews and obtained copies of resident records pertaining to medication error.

On 03/14/2026 at approximately 0930, S1 was at the medication cart preparing meds for a resident. Resident (R1) approached the medication cart and requested their medications. S1 mistook R1 for the resident they were preparing meds for and handed R1 the other resident's medications. S2 observed the mistake and notified the ED, R1's doctor (PCP), Nursing Consultant and the responsible party immediately. Nursing Consultant advised R1 be monitored for any reactions or change in baseline. R1's vital signs were monitored. R1 had no adverse affects to this incident.

On 03/21/2026 S2 was assisting R2, when S2 noticed that R2 had an empty medication cup with the room number of another resident. R2 had received the wrong medications by S1. S2 notified the supervisor on duty, R2's doctor, Nursing Consultant and R2's responsible party. R2 was placed under observation and close monitoring for any reactions. R2 remained at baseline. R2 had no adverse affects to this incident.

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NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2026
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: 03/27/2026
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Continued from 809....

LPA discussed re-training and shadowing of medication technicians.

Copies of relevant records were obtained by LPA.

Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2026 04:35 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 03/27/2026 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MAGNOLIA COURT
FACILITY NUMBER: 486803822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2026
Section Cited
CCR
87465(a)(5)

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87465(a)(5)Incidental Medical and Dental Care: A plan for incidental medical and dental care...The plan shall encourage routine medical and dental care and provide for assistance...with the following:The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Executive Director will submit a plan by 3/30/2026 to ensure that all medication technicians review the rules for proper procedures in medication administration and will go through a re-training including shadowing assessment with facility's nurse prior to administering medications independently.
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Based on self-reported incident reports and interview with Executive Director, S1 gave the wrong medication to resident R1 and R2. This is an immediate health, safety and personal rights risk to residents in care.
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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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Jill Nakagawa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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