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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 04/16/2024
Date Signed: 04/16/2024 01:39:43 PM

Document Has Been Signed on 04/16/2024 01:39 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/
DIRECTOR:		MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Madonna Grace Martinez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. There were 2 care staff and 3 residents at the time of inspection.

Facility was found to be clean and well organized, and a comfortable temperature of 72 F. Residents were clean and dressed appropriately. There was an ample supply of hygiene supplies for residents' care. There was also an ample supply of perishable and non-perishable food as required by Title 22. Water temperature in 2 of 2 bathrooms measured 117.4 -117.9 F., within regulation of 105 -120 F. There was one fire extinguisher that was last serviced on 2/16/2024, fully charged. There were three smoke detectors/carbon monxide detectors which were tested and functional. The last fire drill was held on 2/16/2024. The front and back yards are well-maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are a variety of games and activities. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in closet in hallway.



LPA requested the following updated forms to be submitted to Community Care Licensing by 04/30/24:
1) LIC 308 Designation of Facility Responsibility (1 person per form);
2) LIC 500 Personnel Report;

Continued on 9099-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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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 GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 04/16/2024
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Continued from 9099......

3) Copy of Liability Insurance;
4) LIC 610E Emergency Disaster Plan;
5) LIC 9020 Register of Facility Residents;
6)Copy of Administrator's Certificate;
7) Copy of current Lease/Rental Agreement or Property Tax document
showing control of property
8)Copy of Updated 602's
9)Copy of First Aid/CPR certificates for staff


There were no citations issued during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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