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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 06/02/2026
Date Signed: 06/02/2026 04:13:06 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
05/27/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260527160543
FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:HIQUIANA, KRISTINEFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 92DATE:
06/02/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kristine Hiquiana, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide resident's records to responsible person
INVESTIGATION FINDINGS:
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On 06/02/2026, Licensing Program Analyst (LPA) Nakagawa and Licensing Program Manager (LPM) Mota arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA and LPM met with Kristine Hiquiana, current Administrator (who was not in place at the time of incident) to discuss findings.

The complaint alleges that Staff did not provide resident's (R1) records to responsible person. It is alleged that responsible parties were not provided the Incident Report for 10/27/2024. A review of the Incident Report submitted to the Dept. does not indicate that staff provided a copy to the responsible parties therefore the allegation that Staff did not provide resident's records to responsible person is substantiated. (See 9099-D).

Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Continued on 9099-A.....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
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 3
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
05/27/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260527160543

FACILITY NAME:MAGNOLIA COURTFACILITY NUMBER:
486803822
ADMINISTRATOR:HIQUIANA, KRISTINEFACILITY TYPE:
740
ADDRESS:1111 ULATIS DRTELEPHONE:
(707) 447-7100
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:146CENSUS: 76DATE:
06/02/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kristine Hiquiana, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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3
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9
Medications not given as prescribed
INVESTIGATION FINDINGS:
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On 06/02/2026, Licensing Program Analyst (LPA) Nakagawa and Licensing Program Manager (LPM) Mota arrived unannounced to conduct an investigation regaridng the above allegation and met with Administrator Kristine Hiquiana to discuss.

The complaint alleges that medications were not given as prescribed. The complainant states that on10/27/2024 resident R1 was admitted to the emergency room due to an overdose of medication. Review of medication administration records (MAR) indicate that R1did receive medications as prescribed by physician, therefore the allegation is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260527160543
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: 06/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2026
Section Cited
CCR
87211(a)(1)
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87211Reporting Requirements(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement was not met as evidenced by:
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Licensee to submit copy of Incident Report of 10/27/2024 to responsible parties of R1 within 5 days of receipt.
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Based on review of the Incident Report of 10/27/2024 the report was not provided to responsible parties as required per regulation.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3