197610682-12-23-2025-31-AS-TAGD-DQDQSF-20260116112529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610682
Report Date: 12/23/2025
Date Signed: 12/23/2025 12:38:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2025 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20251217093819

FACILITY NAME:	MAGNOLIA HOME, THE		FACILITY NUMBER:	197610682
ADMINISTRATOR:	SHERMAN, CELENA		FACILITY TYPE:	740
ADDRESS:	6707 SAUSALITO AVE		TELEPHONE:	(661) 236-6787
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	5	CENSUS: 3	DATE:	12/23/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ukarjit Kaur- Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff was unable to provide resident's medical information to emergency services.
Facility staff are not keeping accurate resident records.

INVESTIGATION FINDINGS:

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On 12/23/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by the caregiver and stated the reason for their visit. The Administrator, Ukarjit Kaur arrived shortly after to assist with today’s visit.

To investigate the allegation(s) at 09:35 AM, LPA requested census, resident and staff roster. At 09:45 AM, LPA requested pertinent documentation related to the investigation. At approximately 10:30 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. In Between 10:30 AM – 12:30 PM, LPA attempted interviews with three (3) residents (R1-R3) and two (2) staff members (S1-S2).

(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20251217093819

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAGNOLIA HOME, THE	FACILITY NUMBER: 197610682
	VISIT DATE: 12/23/2025

NARRATIVE

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Regarding the allegation: Facility staff was unable to provide resident's medical information to emergency services. It was alleged that S2 was unable to provide medical information related to a resident in care. To investigate the allegation, LPA attempted interviews with three (3) residents and two (2) staff members. LPA’s interview with R3 revealed that the facility staff will provide medical attention to them if needed and have done so. However, R3 stated that they do not feel comfortable with the Emergency Personnels that have serviced the facility in previous dates, due to their inability to comprehend the severity of their diagnosis. LPA attempted to interview R1 and R2 but they were asleep and could not be interviewed. LPA’s interview with both S1 and S2 revealed that they are able to and have provided medical information for all three (3) residents when Emergency Services have arrived. Further interview with S2, revealed that an isolated incident regarding R1 occurred on 12/16/2025, where Emergency Services were called due to R1 exhibiting a medical episode where their concern for R1’s health and safety arose. S2 stated that emergency personnel were not willing to assess R1 but instead questioned them if they knew when to call for emergency services. LPA’s record review of R1’s Face Sheet showcased medical information such as but not limited to: Primary Insurance, Medications and Resident’s Physician Information. Additional record review of R1’s file confirmed medical information such as their Medical Subscriber Identification, Responsible Person (if any), and Medical Doctor contact information. Further record review of R1’s Admission Record contained additional pertinent information related to R1. Supplementary record review of the Department of Social Services Provider Information Notice (PIN) dated 6/24/2025, examples of when facilities should call 911 for their residents are listed and states, “…In uncertain situations, licensees should prioritize resident health and safety and call 9-1-1 to ensure appropriate medical attention is received” which correlates with S2’s interview that they were concerned for R1’s health and safety.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

(Continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20251217093819

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAGNOLIA HOME, THE	FACILITY NUMBER: 197610682
	VISIT DATE: 12/23/2025

NARRATIVE

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Regarding the allegation: Facility staff are not keeping accurate resident records. It was alleged that facility staff were not maintaining current records related to a resident in care. To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S1 revealed that they have all three (3) residents’ records readily available for review and updated as needed. LPA’s interview with S2, revealed that on 12/16/2025, Emergency Services were called for R1, where they provided R1’s record, although Emergency Personnel did not find the information given to be suffice. During LPA’s record review, LPA confirmed that all three (3) residents’ records were readily available and contained information such as but not limited to: Resident’s Legal Name, Birthdate, Ambulatory status and Centrally Stored Medication. Additional record review of R1’s file confirmed it to contain their Medical Assessment and Needs and Services. Although, LPA observed not all information to be indicated in just one form but in multiple forms, the information required was available if needed. LPA advised S1 to perhaps consolidate residents’ medical information for a more seamless review of documentation.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC9099 (FAS) - (06/04)

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