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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804188
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:19:25 PM

Document Has Been Signed on 11/19/2024 01:19 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 MANORFACILITY NUMBER:
496804188
ADMINISTRATOR/
DIRECTOR:		MATOS, ELIZABETHFACILITY TYPE:
740
ADDRESS:387 MAGNOLIA DRIVETELEPHONE:
(707) 217-3908
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY: 5CENSUS: 3DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Elizabeth Matos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:33 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Elizabeth Matos. Facility contact information was reviewed.

At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA and Admin discussed labeling opened food items with date of opening or date of expiration. Kitchen has a half door that locks and separates the dining area from the kitchen making the entire kitchen area inaccessible to residents.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required grab bars. Admin will add non-skid strips or non-skid mat to each shower. Water temperature in sink accessible to residents in care measured at 106.5 degrees F in the kitchen, 113.4 degrees F in Room#2, and 106.1 degrees F in the main bathroom which are all within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/25/2023. LPA and Admin discussed having the fire extinguishers serviced immediately. Smoke/Carbon Monoxide detector located throughout the facility were tested and operational. Facility does conduct fire drills but has not documented the dates of the drills. LPA and Admin discussed drills must be conducted quarterly and must be documented going forward.

LPA discussed training materials for staff training. Currently Admin is using her facility policies and regulations for training. LPA and Admin discussed using an approved vendor for staff training and purchasing a yearly subscription with an approved vendor.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MAGNOLIA MANOR
FACILITY NUMBER: 496804188
VISIT DATE: 11/19/2024
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Continued from 809...

At approximately 12:00pm LPA conducted review of 4 staff records. S1 did not have a Health Screen on file (deficiency cited, see 809D)



At approximately 12:30pm LPA conducted a review of 3 resident records. All required documentation present. 1/2 rails on file. LPA and Admin discussed adding a shutter door to the entrance of room #3 for resident privacy.

At approximately 1:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked area. No deficiencies

Elizabeth Matos Administrator Certificate 7007055740 expired 11/11/2024. Admin has not started the renewal process or classes yet but will register immediately (deficiency cited, see 809D).



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Copy of Deed

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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Document Has Been Signed on 11/19/2024 01:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/19/2024 at 12:41 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 MANOR
FACILITY NUMBER: 496804188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(a)
Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by: interim Administrator does not have an actively current Administrator certificate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview, and record review, the licensee did not comply with the section cited above in that Administrator's Administrator certificate is expired but not currently in renewal status, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Admin to submit LIC9098 self-certifying they have registered for the Administrator certificate renewal classes.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2024 01:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/19/2024 at 01:01 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 MANOR
FACILITY NUMBER: 496804188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that S1 did not have a Health Screen on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Admin to submit to CCL a current Helath Screen for S1 by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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