486803822-4-8-2022-21-AS-KWAS-CDAS9Y-20220408134130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:42:34 PM

Document Has Been Signed on 04/08/2022 01:42 PM - 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 COURT		FACILITY NUMBER:	486803822
ADMINISTRATOR:	LEHMAN, SIOBHAN		FACILITY TYPE:	740
ADDRESS:	1111 ULATIS DR		TELEPHONE:	(707) 447-7100
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	146	CENSUS: 75	DATE:	04/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Tonya Tucker Tafolla, Director of Resident Care,		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA met with Tonya Tucker Tafolla (TTT), Director of Resident Care. This visit will focus on the infection control of this facility. The facility submitted an infection control mitigation plan on 04/01/2021 which was approved by Community Care Licensing. LPA made the following observations: The facility was clean and a comfortable temperature. Upon entrance of the facility signs are posted on the front door to encourage visitors to wear a mask. In the foyer, the facility has posted their visitor policy, along with disposable mask and hand sanitizer. Front desk staff signed LPA in using a sign-in sheet, and checked LPA's temperature. All staff were wearing face coverings. Resident's visitors were signed in and able to visit with residents in designated area's and bedrooms. LPA observed a 30 day supply of medication and incontinence products. LPA reviewed resident and staff files. Record review revealed that staff have been trained on personal protective equipment and infection control. Continued on LIC 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 04/08/2022 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1)Care of Persons w/Dementia -The following shall be stored inaccessible to residents with dementia... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply w/section cited above in 2 of 2 memory care resident which is an immediate safety risk to person in care. LPA observed Medicated Salve, scissors and mouthwash unlocked and accessible during tour.
	POC Due Date: 04/11/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that toxins, medications & other items that constitute danger to residents are locked & inaccessible at all time. Licensee to conduct an audit of all residents rooms, and inventory items for new residents. Once complete licensee to submit a self-certification that that all items that constitute danger to residents are locked by POC due date of 4/12/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/08/2022

NARRATIVE

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LPA toured the memory care with TTT and observed that residents in the memory care were engaged in activities, other residents were social distanced in the dinning area. In resident R1's bedroom LPA and TTT observed scissors on their tray table. Scissors were accessible to resident. In R2's bedroom LPA and TTT observed a medicated salve and mouthwash. Both Residents R1 and R2 have a dementia diagnosis. TTT immediately removed items and requested the Memory Care Director to do an audit of all resident's bedrooms. (pictures taken)

Siohbhan Lehman, is no longer the Administrator of this facility. LPA requested the following forms to change Administrator by COB on 4/11/22: LIC 215, LIC 500, board of resolution, LIC 308, LIC 501.

The facility received a citation for the deficiency observed above. Appeal rights given. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Tonya Tucker Tafolla, Director of Resident Care.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

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