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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 05/20/2021
Date Signed: 05/20/2021 12:18:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:STOUDER, ROBINFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 64DATE:
05/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Dennis RasmussenTIME COMPLETED:
12:25 PM
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On 5/20/2021 LPA Walters conducted a subsequent Case Management- Incident visit to follow up on an incident report submitted to CCL, and met with Administrator, Dennis Rasmussen and Director of Resident Services, Savannah Arcy. The initial Case Management visit was conducted on 4/28/2021.

On 3/31/2021 it was reported to Community Care Licensing (CCL) that resident, (R1's) cash was missing from their private residence. R1 alleged the individual who removed the cash from their residence was S1. The Administrator notified Law Enforcement, CCL and the Ombudsman to report the theft. An investigation was conducted by the Director of Operations and Vacaville Police Department. S1 was terminated.

The facility was unable to prove or disprove whether or not the S1 removed cash from R1's personal property. An investigation was conducted by the Vacaville Police Department and the investigation is pending any further investigative leads.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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