486803822-12-5-2023-21-AS-KMOA-CYA2WZ-20231206164623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 12/05/2023
Date Signed: 12/05/2023 12:57:47 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
12/04/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20231204144402

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: 84	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yolanda Harrell, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulting in resident falls with injury(ies)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Magnolia Court for the purpose of conducting a 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 investigation, LPA interviewed staff and outside parties, reviewed documents and made observations.

Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). (Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20231204144402

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: 12/05/2023

NARRATIVE

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Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). Review of pre-assessment and Physician's Report establishes that R1 was identified as a fall risk and required assistance as well as needing supervision due to confusion and restlessness prior to move-in. The Special Instructions created for R1's care state an escort to meals and activities will be provided, safety checks will be done at least 3 times per shift, and staff monitoring to maintain independence and safety. Other accommodations were also put in place, including keeping room free of clutter, clear pathway to bathroom and bed to lowest setting. Review of Staff Schedule indicates that staff was present at all times to provide R1's needs and services, monitoring and supervision. The facility provided constant communication with PCP, home health and family regarding the status of R1. Based on interviews, documentation and observation LPA could not substantiate the allegation.

.A finding that the complaint allegation of Neglect/Lack of Supervision resulting in resident falls with injury(ies) 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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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