486803822-11-28-2022-21-AS-CMAZ-CM9U7Q-20221219142017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803822
Report Date: 11/28/2022
Date Signed: 11/28/2022 01:29:20 PM

Unfounded

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
03/14/2022 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20220314214804

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: 79	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Yolanda Herrell		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility failed to seek timely medical attention based on an observed change of condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst arrived unannounced to deliver the findings for the above allegations. LPA met with the Administrator, Yolanda Herrell. The following are the findings of the investigation conducted by the investigations Branch (IB), which involved interviews, records reviews and site observations.

Report continued on 9099 C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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 5

Control Number 21-AS-20220314214804

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: 11/28/2022

NARRATIVE

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On 03/14/2022 the department received a complaint alleging that: the facility failed to seek timely medical attention based on an observed change of condition in R1. An initial visit was conducted on 3/15/2022 to gather additional documentation, make observations and conduct interviews. In addition IB conducted additional interviews and gathered R1’s medical records. Based on the information obtained during the investigation, it was determined that R1 sustained an injury while be assisted by S1 and S2. Staff sought medical attention within minutes of R1 sustaining an injury. R1 received medical attention at the hospital and received subsequent care at a medical facility. Based on the finding it was determined that the allegations are unfounded.

This agency has investigated the complaint alleging facility failed to seek timely medical attention based on an observed change of condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
03/14/2022 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220314214804

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: 79	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Yolanda Herrell		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility is not following residents care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst arrived unannounced to deliver the findings for the above allegation. LPA met with the Administrator, Yolanda Herrell. The following are the findings of the investigation.

On 03/14/2022 Santa Rosa Regional office received a complaint alleging that: the facility is not following resident R1's care plan. During the course of this investigation, LPA made observations, reviewed resident records and conducted interviews. An intial visit was conducted on 3/15/22 at that time, LPA reviewed R1's Needs and Service Plan, home health notes and made observations. During the visit R1's bedroom smelled of urine. Urine could be smelled from the hallway. Interviews from staff and Administrator revealed that R1 had a leaky cathetor. Progress notes from the facility indicate that R1 was recieving home health services for their cathertor and wound care. Staff did not document when home health was notified of the leaky cathetor, however home health was notified and R1 cathetor was replaced on the 3/22/22 by their physcian.
continued on LIC 9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20220314214804

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: 11/28/2022

NARRATIVE

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During the visit on 3/15/22 LPA also observed two staff adjusting R1 in their bed and laying them flat on their back. Nursing notes for R1 state R1 is not to lay flat on their back on the area of their bed sore while they're laying in bed. Home health notes indicate that R1 requires two person assist for bed mobility. Needs and Service plan indicates that the facility will provide assistance when getting in and out of bed and setting up resident for mobility.Therefore, based on interviews conducted, documentation reviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Current Administrator, Yolanda Herrell corrected the deficiency prior to visit by developing a communications logs with assignment sheet and care plans for staff to ensure that all staff are aware of changes in residents care needs. In addition, Administrator developed a ledger for progress notes which allows progress notes to be audited.

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given. Exit interview conducted with licensee/administrator. Reports emailed to licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20220314214804

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: 11/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/02/2022 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) he facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.	1 2 3 4 5 6 7	Current Administrator developed communications logs with assignment sheet and care plans for staff to ensure that all staff are aware of changes in residents care needs.
	8 9 10 11 12 13 14	Based on interviews, record review conducted, Faciltiy did not ensure the regulation above when they did not follow instructions from home health agency for R1 This is a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	In addition Administrator developed a ledger for progress notes which allows progress notes to be audited POC corrected.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5