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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:48:28 PM


Document Has Been Signed on 06/20/2024 04:48 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: 71DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH: Acting Administrator, Mike Chatman and Resident Service Director, Grace MontemayorTIME COMPLETED:
05:00 PM
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On 6/20/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of a Case Management to follow up on Administrator qualifications and were greeted by Acting Administrator, Mike Chatman (AA) and Resident Service Director, Grace Montemayor. The facility is currently in the process of assigning a designated Administrator for the care facility. AA provided proof of administrator re-certification from the Community Care Licensing Administrator Portal. In addition, AA stated that the Licensee is determining the final candidate and will provide LPA's with a time frame on when the Administrator will begin position. The Licensee and AA understand that facility must have active qualified Administrator and that the current status of the facility poses a potential health & safety risk as the previous Administrator had been removed from the facility as of May 16, 2024.

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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