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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:47:27 PM


Document Has Been Signed on 05/23/2023 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:YOLANDA HARRELLFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 85DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Yolanda Harrell, AdministratorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unnanounced to conduct a 1-Year Annual Inspection. LPA met with Yolanda Harrell, Administrator. There were 85 residents in care at the time of inspection. The facility provides both assisted living and memory care.

LPA was welcomed by receptionist and asked to sign the visitor's book. LPA was then joined by Administrator Yolanda Harrell who provided LPA requested records for review. LPA then toured facility with Administrator. 5 resident rooms in memory care were inspected and found to be clean, orderly, and furnished as required by Title 22. The common areas of memory care were well-lit and staff were interacting with residents. An inspection of the Assisted Living residence units found the apartments to be furnished appropriately, with bathrooms having the required grab bars and non-slip mats. Water temperature was within regulation. The ambient temperature of the building was between 72-74 F at the time of inspection. The kitchen was clean and well-stocked with plenty of fresh and frozen foods, as required. The medication rooms for Assisted Living and Memory Care were using an E-Mar system and had the Centrally Stored Medication List available for review. Medications are live-poured and med carts are used for storage and delivery. Facility has a 30-day supply of medication for residents. Nurses are on site daily to help with medication management. The Activities program had multiple activities on the day of inspection: games, a birthday celebration, gardening.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023
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Continued from 809

A quarter of smoke detectors and carbon monoxide detectors are tested monthly. Water temperature is tested monthly. Fire extinguishers were last serviced on October 17, 2022. Safety drills are carried out each shift, quarterly. The last drill was for fire and elopement.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2