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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:49:46 PM


Document Has Been Signed on 04/17/2024 03:49 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: 74DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Yolanda HarrellTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unnanounced to conduct a 1-Year Annual Inspection. LPA was welcomed by receptionist and asked to sign the visitor's book. LPA met with Yolanda Harrell, Administrator. There were 74 residents in care at the time of inspection. The facility provides both assisted living and memory care.

LPA requested personnel and resident records for review. LPA found 5 of 5 resident records and 5 of 5 personnel records well-organized and complete.

LPA then toured facility with Administrator. 10 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. There is a secure area for residents in Memory Care to access an outside walking path or sit outside on several benches. 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 an ample supply of perishable and non-perishable foods, as required per Title 22. LPA inspected fire extinguishers and found 10 out of 10 to be fully charged and last serviced on 11/10/2023. The Fire Department had inspected the facility on 10/1/2023. The facility's last fire drill was held on 2/14/2024. Elevators were last inspected on 6/14/2023.
Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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: 04/17/2024
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Stair chairs were installed at the top of each stairway as required and staff had been given a training on their use. The Hair Salon was in operation during LPA's visit and was found to be clean and sanitary. The medication rooms for Assisted Living and Memory Care use 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 maintenance department had documentation showing their testing and temperature log for hot water.
The facility has many outdoor areas for residents to use. LPA inspected and found them to be free of debris and ready for residents to enjoy.
Administrator's certificate renewal had been processed and was currently pending.

The following documents are requested for submission by 4/30/24:
Current Lease Agreement or Control of Property
Proof of Liability Insurance
LIC 500 - Personnel Report
Updated Disaster Plan

There were no deficiencies found at the time of inspection.
No citations issued.

Exit interview conducted with Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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