486803822-11-16-2023-21-AS-BMOS-CXTSFM-20231122125033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:52:37 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
10/03/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20231003122141

FACILITY NAME:	MAGNOLIA COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR:	YOLANDA HARRELL		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	146	CENSUS: 82	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Yolanda Harrell		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in resident leaving facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Magnolia Court for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility.

During the course of the investigation, LPA interviewed staff, residents and outside parties. LPA reviewed documents during the investigation.

Complaint alleges that Staff does not provide adequate supervision resulting in resident leaving facility. Based on the interviews, LPA could not prove or disprove the allegation. LPA received inconsistent information regarding what actually transpired. LPA reviewed documents and found three Responsible Parties identified on the Emergency Contact form. During the incident in question, the resident left the facility with Responsible Party #3 who is allowed to take the resident on outings and outside of the facility. Facility was made aware that Responsible Party #3 was taking her to the front to get some fresh air, but departed from the facility with the resident shortly after. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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 5

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
10/03/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20231003122141

FACILITY NAME:	MAGNOLIA COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR:	YOLANDA HARRELL		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	146	CENSUS: 82	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Yolanda Harrell		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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9

Staff does not provide adequate information regarding resident to responsible party.

INVESTIGATION FINDINGS:

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3
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5
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7
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9
10
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12
13

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Magnolia Court for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility.

During the course of the investigation, LPA interviewed staff, residents and outside parties. LPA reviewed documents during the investigation.

Complaint alleges that Staff does not provide adequate information regarding resident to responsible party. Based on interviews, LPA learned that staff did not adequately check on the resident (See LIC 809-Case Management-Other inspection dated for November 16, 2023) and in turn provided inadequate information to the Responsible Party (See LIC 9099D). LPA educated the Administrator on the importance of regularly observing the resident as outlined in Title 22 regulations and also providing adequate information to Responsible Parties as outlined in Title 22 regulations. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20231003122141

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: 11/16/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20231003122141

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/27/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.	1 2 3 4 5 6 7	Plan of Correction shall include the Licensee filling out an LIC 9098. In addition, Licensee shall submit a Plan for Future compliance and conduct staff training as it relates to communicating with Responsible Parties.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on an interview with the Administrator, staff did not adequately check on the resident and in turn provided inadequate information to the Responsible Party.	8 9 10 11 12 13 14	POC due date on November 27, 2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20231003122141

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: 11/16/2023

NARRATIVE

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A finding that the complaint allegation of Staff does not provide adequate supervision resulting in resident leaving facility is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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