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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 05:35:37 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
06/10/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240610105634
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:
01:46 PM
MET WITH: Acting Administrator, Mike ChatmanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff block facility exit doors
Staff does not ensure resident's hygiene needs are being met
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, reviewed resident and staff records and made observations during the course of the investigation.

Complaint alleges staff block facility exit doors. Based upon interview with multiple memory care staff, (S1, S2, S3 & S4) there is confirmation of incidents in which staff observed furnishing items being used to block the exits of residents in the memory care unit during evening shifts.

Complaint alleges staff does not ensure resident's hygiene needs are being met. Based upon, facility tour, LPA Mutialu observed resident (R1) on their wheelchair in their bedroom with soiled clothing (photos taken). In addition, based upon interviews with staff (S3 & S4) it was stated that residents have been left in soiled clothing/continence products without timely hygiene services met.

Continued onto LIC9099-C
Substantiated
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 5
Control Number 21-AS-20240610105634
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 block facility exit doors and staff does not ensure resident's hygiene needs are being met, are 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 rights provided.
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 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
06/10/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240610105634

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:
01:46 PM
MET WITH: Acting Administrator, Mike ChatmanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff does not ensure residents are provided a safe environment
Staff does not treat resident with dignity and respect
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, reviewed resident and staff records and made observations during the course of the investigation.

Complaint alleges staff does not ensure residents are provided a safe environment involving staff member allowing family member into the facility. Based upon multiple staff interviews with (S1-S8) there were inconsistent statements and a lack of information gathered supporting the allegation.

Complaint alleges staff does not treat resident with dignity and respect. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of information gathered supporting the allegation.

Allegations, staff does not ensure residents are provided a safe environment and staff does not treat resident with dignity and respect 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 violations occurred. No deficiencies cited.
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: 3 of 5
Control Number 21-AS-20240610105634
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
87303(d)(6)
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87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirements is not met as evidenced by:
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Facility agrees to ensure all exits are free from obstruction and submit a written statement on how facility will remain in compliance by POC date 7/10/2024.
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Based upon interviews, multiple staff (S1, S2, S3 & S4) stated that they have observed memory care unit doors being blocked by furniture, which poses an immediate health and safety risk to resident in care.
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In addition, facility is to hold an in-service meeting with all caregiving staff to discuss compliance concerns of blocked passageways. Signed meeting attendance to be submitted to CCLD by POC date 7/23/2024.
Type A
07/10/2024
Section Cited
CCR
87464(f)
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87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by:
Based upon LPA observation, resident (R1) was found left in soiled clothing (photos taken)
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Facility agrees to submit a written statement on how facility will remain in compliance by POC date 7/10/2024.
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In addition, interviews with staff (S3 & S4) stated observing residents being left in soiled clothing and not properly changed.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5