486803822-12-22-2022-21-AS-CMAZ-CN82PK-20230118163427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 12/22/2022
Date Signed: 12/22/2022 02:04:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220907134554

FACILITY NAME:	MAGNOLIA COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR:	RELPH, JOHN		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	146	CENSUS: 75	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Yolanda Harrell		TIME COMPLETED:	02:16 PM

ALLEGATION(S):

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Staff abused resident in care

INVESTIGATION FINDINGS:

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On this date Licensing Program Analyst (LPA) Katrina Walters arrived unannounced for the purpose of delivering the findings for this complaint, regarding the above-mentioned allegations, and met with Administrator, Yolanda Harrell.

The Santa Rosa Community Care Licensing Regional Office received a complaint on 09/07/2022 alleging that staff S1 physically abused resident R1. An intial visit to open the complaint was conducted on 9/08/22, and subsequent visits occured on 9/15/22 and today, 12/22/22.

Continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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-20220907134554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MAGNOLIA COURT	FACILITY NUMBER: 486803822
	VISIT DATE: 12/22/2022

NARRATIVE

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During the course of this investigation, LPA reviewed resident R1’s: Physician reports (LIC 602), Medication Administration Records (MAR), hospice care notes, needs and service appraisal, charting notes, staff training records, time sheets, call button reports and records from the Vacaville Police Department. In addition to reviewing resident and staff documentation, LPA made observations and conducted interviews with staff, Previous and Current Administrator, Hospice Health Agency, Responsible Parties and Residents.

The following determinations were made based on the information gathered: Interviews and records reveal that there were no witnesses to the alleged abuse. Statements from interviews reveal that on 9/3/22 a red mark appeared on the left side of R1's face. (pictures taken). Pictures taken by staff dated 9/3/22 indicate that R1 had dryness and red discoloration on the left side of their face. There were conflicting statement of what may have caused the red discoloration/rash to appear on R1's face. A day prior to the discoloration/rash appearing on R1's face, R1 received was bathed by a home health aid and according to R1's (602) Physician Report and statements from the Hospice agency R1 has significant skin breakdown, and dryness of the skin, which could've resulted in R1 having a rash/skin breakdown on their face. Once the discoloration was observed the facility ensured that the hospice agency and the responsible parties were made aware. Therefore, LPA was unable to determine what caused the skin discoloration and if there was any physical abuse that occurred.

A finding that the complaint allegation: Staff abused resident in care is UNSUBSTANTIATED, meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited during this visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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