486803895-12-8-2023-21-AS-KMOA-CYH2BG-20231213161507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803895
Report Date: 12/08/2023
Date Signed: 12/08/2023 01:37:54 PM

Unsubstantiated

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
08/01/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20230801082339

FACILITY NAME:	MAGNOLIA GOLD HOME CARE		FACILITY NUMBER:	486803895
ADMINISTRATOR:	MARTINEZ, MADONNA GRACE		FACILITY TYPE:	740
ADDRESS:	1515 MARIPOSA WAY		TELEPHONE:	(707) 759-5269
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2023
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Ethel Valenzuela, Caregiver		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulting in severe and unexplained injuries

INVESTIGATION FINDINGS:

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On 12/8/2023, Licensing Program Analyst (LPA) Nakagawa arrived unannounced for the purpose of delivering complaint investigation findings and a was greeted by Carestaff. During the course of the investigation, the facility was toured, staff and outside parties were interviewed, resident and facility records were reviewed, and observations made.

Investigation was conducted and completed by Community Care Licensing Investigations Branch (IB) investigator and the following was reported.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230801082339

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: 12/08/2023

NARRATIVE

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Continued from 9099...

On 7/29/2023, Resident (R1) was transported to Kaiser Permanente Vacaville for bruising on the chest/right side. R1 was diagnosed with rib fractures to the left side that were in the healing stage. Medical records note the R1 sustained fractures to the left eighth, ninth and tenth ribs, bruising to the right side and hematoma on the right-side chest wall. R1’s physician reported that the injuries sustained could have been a result of trauma such as a fall. R1’s physician reported the injury pattern was not suspicious for physical abuse.

Staff interviewed reported that R1 was non-ambulatory and required two person assist to and from bed. R1 was unable to walk and could only stand with assistance. Facility staff reported that R1 never had a witnessed or unwitnessed fall while living at the facility.

Due to a lack of corroborating evidence to determine how the bruising, fractures and hematoma developed or as a result of physical abuse, the allegation is found to be unsubstantiated. Allegation, neglect/lack of care and supervision resulting in severe and unexplained injuries is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Appeal Rights given.

No deficiencies cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC9099 (FAS) - (06/04)

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