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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 11/12/2024
Date Signed: 11/12/2024 02:12:31 PM

Substantiated


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
08/26/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240826150840
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: 80DATE:
11/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Due to a lack of staff, residents are not assisted with feeding

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrator Candice Moses.

The complaint alleges that due to a lack of staff, residents are not assisted with feeding. LPA reviewed documents and conducted interviews which revealed that 2 of 28 residents in memory care, residents R1 and R2, require assistance with feeding. There are additional residents, R3 and R4 who require constant re-direction to eat and/or assistance in cutting their food and receiving proper utensils.

Continued on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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 4
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
08/26/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240826150840

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: 80DATE:
11/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Due to a lack of staff, residents are not showered timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrator Candice Moses.

The complaint alleges that due to a lack of staff residents are not showered timely. LPA reviewed shower records for the month of August and found that residents were showered according to the care plan. LPA observed on several dates: 8/22/2024, 8/27/2024, 9/27/2024 and 11/12/2024, that residents were clean and dressed appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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 4
Control Number 21-AS-20240826150840
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: 11/12/2024
NARRATIVE
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Continued from 9099.....

LPA also observed that residents with dementia are not being supervised when being served meals in their rooms (resident R3) with food not being eaten due to lack of direction and food being served improperly (not cut up into bite size pieces) as residents are not supplied with knives for their safety. Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation that due to a lack of staff, residents are not assisted with feeding is found to be substantiated is being cited on the attached LIC 9099D.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240826150840
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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) ... Personal Rights of Residents... following personal rights: (4) To care, supervision, and services that meet... need delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by:
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Administrator to provide CCL with an update LIC-500 showing adequate staffing for all shifts by 11/14/2024
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:Based on interviews conducted and LPA’s observations of residents being unsupervised during feeding the Licensee failed to ensure that residents were assisted with feeding. This serves as an immediate health & safety and personal rights risk to residents in care.
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and Administrator to provide in-service training for all caregiving staff to review care and feeding of residents in Dementia Care. Administrator to submit scheduled training date to CCLD by POC date 11/14/2024 and submit completed signed training log to CCLD by POC date 11/21/2024.






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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4