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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:35:04 PM

Document Has Been Signed on 06/26/2024 03:35 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
SANTA ROSA RO, 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: DATE:
06/26/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Licensee/Administrator, Madonna MartinezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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A non-compliance conference was conducted today in the Santa Rosa Regional Office. Present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, and Facility Licensee/Administrator, Madonna Martinez. An informal office meeting was conducted on 6/12/2024, to discuss areas of non compliance. Licensee was requested to submit documents by close of business 6/14/2024, and failed to do so. The purpose of today's meeting is to review ongoing compliance concerns.

This non-compliance conference is being conducted to discuss concerns identified by community care licensing in regards to the operation of Zealcare Home, 286804025 and Magnolia Gold Home Care, 486803895. Areas of noncompliance not limited to below were discussed:
  • Administrator Duties and Qualifications
  • Active Administrator in place for facility oversight per regulation
  • Clearing POCs
  • Reporting Requirements
  • Timely response to CCL when communication is engaged


LIcensee was informed of Technical support program and agrees to engage in services.

No deficiencies sited during this noncompliance conference.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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