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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 05/26/2022
Date Signed: 05/26/2022 01:11:03 PM

Document Has Been Signed on 05/26/2022 01:11 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 GOLD HOME CAREFACILITY NUMBER:
486803895
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Rosalina Alvia, caregiver TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rosalina Alvia, caregiver. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility and observed 5 residents in care. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Staff have CPR/first aid certifications. Fire extinguisher was charged and serviced 10/01/2021. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. During this visit, LPA verified staff vaccinations, *Administrator to send vaccine verification to LPA for staff's vaccine records that were not in file.
LPA discussed the following requirements with caregiver:
· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit.
LPA requested the following updated forms to be submitted to Community Care Licensing by 06/16/2022
· LIC 308 Designation of Facility Responsibility (1 person per form); LIC 500 Personnel Report; LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents); Copy of liability insurance; LIC 610E Emergency Disaster Plan; LIC 9020 Register of Facility Residents; Copy of current Administrator's Certificate; Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with Rosalina Alvia, caregiver, whose signature on this document confirms receipt.
*No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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