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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:39:34 AM

Document Has Been Signed on 10/06/2022 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:RELPH, JOHNFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 146CENSUS: 80DATE:
10/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Mike ChapmanTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) arrived unannounced to follow up on a self-reported incident. LPA met with Mike Chapman, Operation Specialist (MC).

It was self-reported to Community Care Licensing that on 9-12-22, resident (R1) had an un-witnessed fall in their bedroom. (R1) complained of pain. Staff (S1) contacted the responsible party, who denied to take (R1) to the hospital or for them to contact emergency services. Facility staff were unable to medically assess resident and whether they needed treatment. R1 had an additional fall the next day and complained of pain. Facility staff then contacted emergency services. Therefore the facility delayed seeking medical treatment for resident (R1). The un-witnessed fall did not result in any injuries.

LPA reviewed resident records and interviewed resident and staff. LPA made observations with MC. LPA and MC learned that R1 had multiple falls due to the framework of their bed. MC will have a care conference with R1's responsible parties and discus alternative's to prevent the resident from falling out of bed. In addition, all staff will undergo an in-service of when to seek emergency medical treatment for residents and send proof to LPA by POC due date.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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Document Has Been Signed on 10/06/2022 11:39 AM - It Cannot Be Edited


Created By: Katrina Walters On 10/06/2022 at 11:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MAGNOLIA COURT
FACILITY NUMBER: 486803822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2022
Section Cited
CCR
87465(a)(1)

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87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Facility to submit poof of in-service, that they understand when to seek medical care for residents. Administrator to send proof of in-service by POC due date 10/11/22, to LPA Walters.
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Based upon records reviewed and statements taken, this requirement has not been met as evidenced by: Records and interviews revealed that the facility delayed medical treatement for R1. This poses a pontential health and safety risk to residents in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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