486803822-7-9-2024-21-AS-VBEI-D7K2A7-20240726171304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:12:02 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
05/28/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240528094749

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:	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Acting Administrator, Mike Chatman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in residents leaving facility

INVESTIGATION FINDINGS:

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On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties, reviewed resident and facility records and made observations during the course of the investigation.

Complaint alleges staff does not provide adequate supervision resuliting in residents leaving facility. Based upon review of facility incdient reports it was found that on the evening of 5/22/2024, resident (R1) had been found out in the community unassisted. Based upon a review of R1's Physicain's Report it is indicated that R1 is diagnosed with dementia and resides in the memory care unit. In addition, review of the Preplacement Appraisal indicates that R1 required special observation/night supervision due to confusion, forgetfullness and wandering. Lastly, review indicated contracdicting information on R1's physician's report regarding R1's capabilities. Facility was requested to updated R1's documentation.
Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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 5

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
05/28/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240528094749

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:	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Acting Administrator, Mike Chatman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not provide adequate information regarding resident to responsible party
Due to lack of supervision, resident on resident assaults occur

INVESTIGATION FINDINGS:

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On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties, reviewed resident and facility records and made observations during the course of the investigation.

Complaint alleges staff does not provide adequate information regarding resident to responsible party pertaining to resident on resident altercations not being reported to responsible parties. Based upon a review of facility incident reports, it was found that on 5/21/2024 and 6/19/2024, resident (R2) had been involved in physically aggressive altercations with other residents (R3 & R4). Upon review of facility incident reports, it is indicated that residents' (R3 & R5) responsible parties were notified. Lastly, upon interviews with R5's responsible parties (I1 & I2), the facility had provided notification of the incident.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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 5

Control Number 21-AS-20240528094749

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: 07/09/2024

NARRATIVE

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Complaint alleges due to lack of supervision, resident on resident assaults occur. Based upon a review of facility records and incident reports, it was found it was found that on 5/21/2024 R2 had been reported to demonstrate physically aggressive altercation with resident R3. Based upon a review of facility and resident medical records it was found that the facility notified R2's physician of the incident and implemented a medication change and increased redirection based on observed aggression. Record review also indicated that on 5/23/2024, R2 was observed by staff, attempting to choke resident (R4) but with staff successfully being able to redirect R2. This also indicates facility is implementing care intervention. Lastly, resident records indicate that the facility had contacted R2's family to discuss increased supervision. Due to a lack of corroborating information the allegation is found to be unsubstantiated.

Allegations, staff does not provide adequate information regarding resident to responsible party
and due to lack of supervision, resident on resident assaults occur are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20240528094749

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: 07/09/2024

NARRATIVE

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Allegation, staff does not provide adequate supervision resulting in residents leaving facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20240528094749

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: 07/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/10/2024 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review of facility incident reports and resident records it was found that resident (R1) had eloped from the facility	1 2 3 4 5 6 7	Facility agrees to conduct staff training regarding elopements & updated R1's Physician's Report to better indicate their capabilities matching the level of care needed. Facility is to submit training date to CCLD by POC date 7/10/2024 and completed training by 7/23/2024.
	8 9 10 11 12 13 14	without supervision. R1 is diagnosed with dementia and based upon appraisal, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.	8 9 10 11 12 13 14	In addition, facility is to submit updated physician's report for R1 by POC date 7/23/2024.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

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