486803822-9-27-2024-21-AS-CMAZ-D9NK7X-20241002073950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:28:40 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
05/23/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240523083545

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:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Candice Moses, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are not allowing resident to have visitor(s)

INVESTIGATION FINDINGS:

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LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with the new Administrator, Candice Moses.

Facility staff are not allowing resident to have visitor(s) – Complaint alleges that facility staff are not allowing resident to receive visitors. Per interviews, it was confirmed that the facility stopped visitation for individuals as directed by a resident’s responsible party. No documentation was provided to allow for this action.

Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Continued on 9099-D

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
05/23/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240523083545

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: 77	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Candice Moses, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained multiple injuries due to staff neglect
Facility is not meeting resident's care needs
Facility staff handle the resident in a rough manner
Facility staff are not ensuring resident privacy

INVESTIGATION FINDINGS:

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LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with the new Administrator, Candice Moses.

Resident sustained multiple injuries due to staff neglect – Complaint alleges that resident got a yeast infection due to poor hygiene as well red skin that looked like “burns” due to staff not providing adequate incontinence care. Complainant also alleges that resident went to the hospital where they were diagnosed with a blood clot from resident being left in bed by staff instead of assisting with ambulating as needed. Per complainant, resident had an unwitnessed fall in their room at night and sustained a broken arm, also due to staff not assisting with ambulating as needed. Resident’s care plan indicates they are a “standby assist” with transferring, ambulating, toileting, and showering. It was confirmed through review of records that resident had a fall resulting in a broken arm.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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 4

Control Number 21-AS-20240523083545

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: 09/27/2024

NARRATIVE

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Continued from 9099-A
Per review of Special Incident Report, resident was being assisted to their bed by staff when they suddenly fell resulting in a broken arm. CCL was unable to confirm through interviews or record review that resident sustained multiple injuries due to staff neglect as indicated in the complaint.

Facility is not meeting resident's care needs – Complainant alleges multiple instances where resident’s care needs were not met including, but not limited to, facility staff failing to send resident to the doctor when a growth was found on their face which turned out to be skin cancer, resident not being showered and only receiving sponge baths, which contributed to them getting a Urinary Tract Infection (UTI) and that resident was not having their face washed or teeth brushed. Per interview, resident received bed baths while they had broken arm but staff denied bed baths at any other time. CCL was unable to confirm through interviews or record review that staff failed to respond to resident’s care needs as indicated in the complaint.

Facility staff handle the resident in a rough manner – Complaint alleges that a staff was observed pulling a resident up by one arm, not allowing them to catch their balance, and then dragging them by their arm to the bathroom to wash them using wet toilet paper with no soap to wash the resident in the bathroom. Interviewed staff denied dragging resident and using wet toilet paper to wash resident. CCL was unable to confirm through interviews or record review that staff handled resident in a rough manor and used toilet paper to wash them as indicated in the complaint.

Facility staff are not ensuring resident privacy – Complaint alleges that another resident goes into Resident, R1’s room. Despite R1 expressing that they don’t want them to come in, staff do not ensure that resident does not go into other residents’ rooms. Per interviews, staff attempt to redirect residents and will lock rooms at the request of a resident. CCL was unable to confirm through interviews or record review that staff are not ensuring resident privacy as indicated in the complaint.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20240523083545

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: 09/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/27/2024 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1(a)(11) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.	1 2 3 4 5 6 7	Licensee will ensure that residents rights are maintained. Licensee will submit a self-certification (LIC9098) that all staff had been notified about regulation by POC due date of 09/30/2024.
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not comply with the section cited above when they stopped visitation at the direction of the resident’s responsible party which poses an immediate personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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