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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701190
Report Date: 11/17/2022
Date Signed: 11/18/2022 10:51:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220919105510
FACILITY NAME:MAGNOLIA CARE HOME 1FACILITY NUMBER:
392701190
ADMINISTRATOR:SOUMAHORO, MARIAM G.FACILITY TYPE:
740
ADDRESS:4727 SONGWOOD COURTTELEPHONE:
(209) 982-1457
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Elizabeth CastilloTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Illegal eviction.
Facility did not communicate with authorized representative of resident's change of health.
INVESTIGATION FINDINGS:
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Based on records reviewed and interview with the Administrator the facility sent R1 out to the ER to be assessed for health concerns. The facility did not pick-up or make for arrangements for R1 to come back to her home after the hospital assessed R1 and determined that she would be placed on hospice. The information given to the discharge planner at the ER was that R1's family was given a 30 day notice and that the hospital should call the family to determine where R1 should be discarded to.

The facility sent me a text message saying that R1's rent increase would take place on August 4 the same day they said her level of care changed. On 8/16 the facility gave the family a 30 day notice to move R1.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220919105510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190
VISIT DATE: 11/17/2022
NARRATIVE
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On 8/23 the stated that R1 was out of pull up, so the family dropped them off. On September 16, 2022, the family sent the rent as normal and later that day the facility sent the payment back. On 9/17/22, the family received a text message that R1 is at St Joseph ER.

The facility did not follow-up with the ER to determine if the discharge would require a higher level of care, aside from the fact that she was now or possibly would be placed on hospice.

The Facility has a hospice waiver for three and therefore could have provided R1 with the alleged or required care to meet R1's needs.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The following deficiencies was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220919105510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MAGNOLIA CARE HOME 1
FACILITY NUMBER: 392701190
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2022
Section Cited
CCR
87224(b)
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87224 Eviction Procedures
(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility.
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Licensee will write a letter acknowledging understanding of regulation and submit to LPA by POC date.
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This regulation was not met as evidence by based on the interviews conducted, the licensee did not ensure proper procedures and approval was received prior to not accepting the resident back into care. This poses a potential risks to resident in care.
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Type B
12/02/2022
Section Cited
CCR
87463(a)
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Reappraisals. (a) The pre-admission appraisal shall be updated in writing…as frequently as necessary to note significant changes and to keep the appraisal accurate.
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Licensee will develop a plan to ensure all resident appraisals are updated as appropriate to meet the needs of residents in care. Plan to be submitted to LPA by POC due date.
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This requirement is not met as evidenced by: text message saying that R1's rent increase would take place on August 4 the same day they said her level of care changed. On 8/16 the facility gave the family a 30 day notice to move R1. This poses a potential health and safety risk to residents in care.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3