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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 06/30/2026
Date Signed: 06/30/2026 02:25:15 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
06/24/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260624081450
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: DATE:
06/30/2026
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Kristine Hiquiana, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not provide adequate supervision resulting in resident eloping.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA met with Administrator Kristine Hiquiana.

The complaint alleges that Staff do not provide adequate supervision resulting in resident eloping. The complainant states that on June 12, 2026, resident R1 eloped from the facility at approximately 5:30 AM using the delayed egress door by their room in the memory care unit. R1 was spotted by staff and followed while off property until police were able to come and assist R1, who was uncooperative and combative, back safely to the facility. R1 was assessed and found to have no injuries.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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
Control Number 21-AS-20260624081450
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: 06/30/2026
NARRATIVE
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(Continued from 9099)

LPA reviewed records which included the facility's internal investigation forms, incident report, and staff accounts which included a statement from care staff who admitted to falling asleep. A review of R1’s Physician’s Report (LIC602) indicates R1 is unable to leave the facility unassisted. (Deficiency cited).

Based on interviews, statements received, records reviewed and LPA's observations, the preponderance of evidence standard has been met. Therefore, the above allegation that Lack of Supervision resulting in Elopement is SUBSTANTIATED. (Deficiency cited.)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

An immediate civil penalty is being issued in the amount of $500 per Health and Safety Code 1568.0822(C)(3) Absence of Supervision. An additional $500 is being issued for arepeat violation within a 12-month period.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260624081450
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: 06/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2026
Section Cited
CCR
87411(a)
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Personnel Requirements – General 87411(a) –Personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
This requirement was not met as evidenced by:
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A $500 immediate civil penalty was assessed, and a $500 penalty for a repeat violation (7/17/2025).
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Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.
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Licensee/Administrator to submit in-service retraining to all staff on elopement protocols.

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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: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3