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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:33:06 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
07/08/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240708160837
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: 77DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:Candice Moses, AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
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8
9
Staff did not follow protocols to prevent the spread of illness.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with Candice Moses, the newly appointed Administrator.

Staff did not follow protocols to prevent the spread of illness – Complaint alleges that covid positive cases were not being reported and positive residents were walking around. Per interview, facility reported a Covid outbreak on 7/7//2024 to the local public health department and created a Special Incident Report for CCL on 7/8/2024. CCL received the report on 7/9/2024. Per the Special Incident Report, a third resident tested positive on 7/7/2024, which prompted the facility to report the Covid outbreak, per local public health requirements. Per interview, Covid positive residents isolated well, except one Memory Care resident who had to be redirected frequently. When the resident refused to isolate, facility staff asked them to mask and attempted to provide distance between resident and Covid negative residents who were not required to isolate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited during inspection.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 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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