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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803895
Report Date: 03/04/2022
Date Signed: 03/04/2022 06:13:07 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
08/27/2021 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210827080854
FACILITY NAME:MAGNOLIA GOLD HOME CAREFACILITY NUMBER:
486803895
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Madonna Martinez, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff failed to follow the resident's dietary plan

Staff are not taking any precautions for COVID-19
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Canela arrived at Magnolia Gold Home Care for the purpose of delivering findings on complaint # 21-AS-20210827080854. LPA met with Madonna Martinez, Administrator
LPA investigated the above allegations.

During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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-20210827080854
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 GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 03/04/2022
NARRATIVE
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It was reported that the facility staff did not follow Resident (R1)’s diabetic dietary plan due to staff feeding R1 high sugar foods such as bananas, apple pie, peanut butter & jelly sandwiches. Interviews determined Administrator bought the food items and staff did not follow R1's dietary plan in which R1 was fed those items on a daily basis because R1 requested it. Administrator stated they wanted to ensure R1's personal rights to choose their food & snack items. However, the facility failed to notify the doctor and it was not approved in R1's diabetic dietary plan.

It was alleged the facility did not follow COVID-19 precautions. Based on LPA observations, outside interviews, and facility records, it was revealed that staff did not follow COVID-19 precautions. LPA received corroborating statements from outside resources that staff were observed without wearing masks indoors as required. Records revealed there was a lack of documentation for COVID-19 procedures. Additionally, LPA's temperature was not taken on inspection visit dated 09/02/2021.


Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6), are being cited on the attached LIC 9099-D. Appeal Rights Provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20210827080854
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 GOLD HOME CARE
FACILITY NUMBER: 486803895
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2022
Section Cited
CCR
87555(b)(7)
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87555General Food Service Requirements - (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by:
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 Administrator to train staff on regulation 87465(h)(2) and submit documentation of training with date, time, subject, duration, staff names and signatures of attendance.
POC due date 03/11/2022 to Community Care Licensing to clear the citation.
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Based on interviews and records reviewed, the facility failed to ensure resident (R1) was following a modified diet according to their diabetic diagnosis. Staff provided food items such as apple pie and peanut butter sandwiches because resident had requested it.
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Administrator failed to notify R1’s physician and continued to provide high sugary foods to R1. This is an immediate health & safety risk to the residents in care.
Type B
03/11/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities -(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by:
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Administrator to submit a statement that they understand the regulation and shall be in future compliance. Statement to be submitted to CCL to clear the citation by POC due date 3/11/2022
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Based on interviews, records reviewed,and observations made, the facility did no ensure the regualtion due to staff observed without wearing a mask and not screening visitors for COVID symptoms. This is a potential health & safety risk to 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
08/27/2021 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210827080854

FACILITY NAME:MAGNOLIA GOLD HOME CAREFACILITY NUMBER:
486803895
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Madonna Martinez, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not dispense medication per physicians orders
Staff violated resident's personal rights by bitting resident
Resident was not provided water which caused resident to be dehydrated
Staff failed to seek medical attention for resident in a timely manner
Staff failed to provide activities for resident in care
Staff left resident in wet diapers for extended periods of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Canela arrived at Magnolia Gold Home Care for the purpose of delivering findings on complaint # 21-AS-20210827080854. LPA met with Madonna Martinez, Administrator
LPA investigated the above allegations.

During the investigation, LPA conducted interviews, reviewed the facility file, inspected the facility, obtained and reviewed records.


Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20210827080854
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 GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 03/04/2022
NARRATIVE
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Staff did not dispense medication per physicians orders: There were a lack of witnesses and documentation to corroborate the allegation. LPA reviewed the facility's Centrally Stored Medication log and Medication Administration Record, documentation did not indicate medication was not given as prescribed. Additionally, a statement from R1's hospice agency indicated there were no concerns or evidence to support that staff had not dispensed R1's medication per physician's orders.
Staff violated resident's personal rights by bitting resident: LPA did not receive a date or time of which the incident allegedly occurred. There were a lack of witnesses and documentation of any injuries sustained to corroborate the allegation.
Resident was not provided water which caused resident to be dehydrated: Interviews revealed staff provide individual water containers for residents to stay hydrated. A lack of witnesses and documentation of dehydration occurring with R1 and LPA did not received a date of when the alleged incident occurred.
Staff failed to provide activities for resident in care: Statements received indicated R1 would often watch television shows in their room and did not want to participate in other activities.
Staff left resident in wet diapers for extended periods of time: Statements received revealed R1 had a supply of incontinent briefs and would use them. Hospice chart notes did not indicate skin break down or concerns of leaving R1 soiled for extended periods of time. Statements did not corroborate the allegation.
Staff failed to seek medical attention for resident in a timely manner: LPA did not receive confirmation of a date or time of which the incident allegedly occurred. Discharge paperwork revealed R1 was seen in March 2021. There were a lack of witnesses and corroborating statements of staff not contacting medical services in a timely manner.
Due to the contradicting statements received and lack of witnesses to the incidents alleged, as well as all the information gathered, The Department was not able to corroborate the allegations. LPA has investigated the complaint alleging “Staff did not dispense medication per physicians orders; Staff violated resident's personal rights by bitting resident; Resident was not provided water which caused resident to be dehydrated; Staff failed to seek medical attention for resident in a timely manner; Staff failed to provide activities for resident in care; Staff left resident in wet diapers for extended periods of time”.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. We have therefore dismissed the complaint. An exit interview was conducted with Madonna Martinez, Administrator whose signature on this form confirms receipt of these documents.

No deficiencies cited regarding the above allegations during today’s visit.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5