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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:19:05 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
06/17/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240617155026
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: DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Acting Administrator, Mike ChatmanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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2
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8
9
Staff hit resident
Staff screams at residents
INVESTIGATION FINDINGS:
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13
On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & 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 and made observations during the course of the investigation.

Complaint alleges facility staff hit resident. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation.

Complaint alleges staff screams at residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (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 2
Control Number 21-AS-20240617155026
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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Allegations, staff hit resident and staff screams at residents are found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means 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. Appeal Rights given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (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: 2 of 2