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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 12/02/2021
Date Signed: 12/02/2021 12:31:37 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210817084613
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: 78DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tonya Tucker TafollaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained a fracture during care
Facility failed to provide care resulting in resident injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Tonya Tucker Tafolla and discussed the findings. During the course of this investigation statements were taken, records were obtained and reviewed, and site visits completed. Based upon the statements and records, the following determinations are made: R1 fell and sustained a fracture during a supervised class at the facility; It is alleged that the injury resulted from a lack of care and supervision by facility staff; R1's medical assessment indicates non ambulatory, lacking significant mental impairment, no limitations of physical activity; R1's Care Plan indicates independent for locomotion, stand by assistance with dressing; Witnesses to the fall have not provided evidence to suggest it resulted from a lack of care or supervision; R1 does not recall details of the incident. Although the allegations may be true, based upon the records reviewed and statements taken, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210817084613

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: 78DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tonya Tucker TafollaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff stole resident’s medications resulting in resident not receiving medication as prescribed.
Resident’s medication was not stored in the originally received container

INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Ms. Tafolla and discussed the findings. During the course of this investigation, records were obtained and reviewed; statements were taken from witnesses and staff; site visits made to the facility. Based upon the records and statements, the following determinations are made: Numerous incidents involving medication errors and thefts have been self-reported by facility to CCL and Law enforcement in the recent past; Medication thefts reported in June, July, and August of 2021; On or about August 11, 2021, R1 was requesting medication for pain and it was determined that the pain medication container contained stool softeners and not the narcotic; On or about August 17, 2021, Administrator reported oxycodone had been replaced with Tylenol in the containers of two residents in care. Based upon the statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are sustained. The following deficiencies were observed (see LIC 9099D) 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
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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-20210817084613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COURT
FACILITY NUMBER: 486803822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. *** Based upon records and statements, this requirement has not been met as evidenced by: Facility reports several incidents where residents’ pain medications were replaced by other, non –
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Administration shall submit a written plan to CCL by POC date in order to clear the deficiency. Plan shall address the steps to be taken by facility to insure medications are administered as ordered and in compliance with requirements of 87465.

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narcotic over the counter medications. This posed an immediate risk to the health of the residents in care.

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Type A
12/06/2021
Section Cited
CCR
87465(c)(5)
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 Incidental Medical and Dental Care. Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. **Based upon statements and records, this requirement has not been met
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Administration shall submit a written plan to CCL by POC date in order to clear the deficiency. Plan shall address the steps to be taken by facility to insure medications are stored in original containers and in compliance with requirements of 87465.


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as evidenced by: Facility reports several incidents where residents’ pain medications were replaced by other, non – narcotic over the counter medications. This posed an immediate risk to the health of the 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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3