486803822-3-30-2021-21-AS-KMOA-BZVVBT-20210408161805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 03/29/2021
Date Signed: 03/30/2021 08:19:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20201109085240

FACILITY NAME:	MAGNOLIA COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR:	STOUDER, ROBIN		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	146	CENSUS: 86	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	02:06 PM
MET WITH:	Savannah Beddell, RSD/LVN		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility staff did not notify resident's authorized representative of the resident's condition
Communications to the licensee from resident representatives not answered promptly and appropriately

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tobola conducted a complaint investigation to deliver findings regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with RSD/LVN Savannah Beddell by tele-visit. Facility documents, resident records were reviewed and interviews with staff and other outside parties were conducted.

The complaint alleges that facility staff did not notify resident's authorized representative of resident's condition. Based on review of facility documents and resident records it was found that the facility notified resident (R1's) authorized representative and Physician of R1's changes of condition and was able to provide some communication records between the facility and R1's authorized representative. However, based on interviews with staff and outside parties LPA received conflicting information and found that although the facility did provide some proof of notification of R1's change of conditions to R1's authorized representative LPA did not receive enough corroborating evidence to prove or disprove the allegation.

Report continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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 21-AS-20201109085240

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAGNOLIA COURT	FACILITY NUMBER: 486803822
	VISIT DATE: 03/29/2021

NARRATIVE

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The complaint alleges communications to the licensee from resident representatives were not answered promptly and appropriately. Based on a review of facility communication records and resident records LPA found that the facility management staff had been in contact with R1's responsible party about R1's health status and responded appropriately to questions. However, based on multiple interviews with staff, Complainant and outside parties, LPA was provided with contradicting information regarding promptness of contacting R1's authorized representative and that although the facility did provide notification of R1's condition to R1's authorized representative in a timely manner it wasn't as often as requested. LPA was unable to find corroborating evidence towards the allegation.

A finding that the complaint allegation facility staff did not notify resident's authorized representative of the resident's condition and communications to licensee from resident representative were not answered promptly and appropriately are UNSUBSTANTIATED meaning that although the allegations may have happened, there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies were cited during today's visit. Signatures on file.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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