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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803822
Report Date: 09/02/2022
Date Signed: 09/02/2022 09:06:05 AM


Document Has Been Signed on 09/02/2022 09:06 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: 74DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Amber EbertTIME COMPLETED:
09:15 AM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC 341, Report of Suspected Dependent Adult/Elder Abuse, submitted by the facility on 08/23/2022. LPA met with Business Office Manager Amber Ebert, interviewed staff and reviewed records. The SOC 341 was in regards to a resident, R1, reporting that $200 was stolen from their room sometime during 08/19/2022. LPA received a copy of the investigation conducted by the facility. The facilities investigation was thorough and detailed. R1 told staff that they thought they saw a "black man" in their room the night before. LPA reviewed the staffing schedule for the week in question with Amber and there were no staff matching that description. The facilities investigation noted that when they went to the room of R1 to question them, the wallet was sitting in the open and the door was left open to the hallway. Facility staff continue to remind R1 to keep their valuables in the rooms secure storage and to close their door while not in the room. The facility reported the incident to local law enforcement, responsible person, the Ombudsman office and Licensing.
LPA received a copy of the facilities Theft and Loss policy. LPA reviewed the policy and found they followed their protocols in the way this incident was handled.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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