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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:23:25 PM

Document Has Been Signed on 05/26/2023 02:23 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: 6DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Madonna Martinez, AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Madonna Martinez, Administrator.
LPA toured the facility and observed all exits were unobstructed. The facility was found to be at a comfortable temperature.
Fire extinguisher was charged and serviced 02/16/2023. There are 8 hardwired combination smoke and carbon monoxide detectors. LPA observed a supply of PPE, linens (bedding, towels, etc.), and disinfectants/cleaning solutions. Liquid hand soap and paper towels are available in bathrooms. Bedrooms were furnished per regulation. Facility food supply was within regulation. Medication was centrally stored and locked. LPA reviewed staff and resident records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) . The facility does not handle resident cash resources. The facility's backyard in-ground swimming pool is fenced and locked.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/26/2023:
    · 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
    · Copy of current Administrator's Certificate
    · Addendum to admission agreement regarding video surveillance
    · LIC625 completed for residents
    · Doctor's Orders & Hospice Care Plan for postural supports (assistance with mobility)
Exit interview conducted with Administrator, 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: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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