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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 07/29/2025
Date Signed: 07/29/2025 01:31:23 PM

Document Has Been Signed on 07/29/2025 01:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MAGNOLIA GOLD HOME CAREFACILITY NUMBER:
486803895
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
07/29/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Caregiver Martha ReyesTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At approximately 9:45 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Martha Reyes who has Designation of Facility Responsibility (DFR). Administrator Madonna Martinez was called to advise of NCC inspection, but was not able to attend as she was at a sister facility.

This facility was placed on a non-compliance (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/26/2024 were:
  • Administrator Duties and Qualifications
  • Active Administrator in place for facility oversight per regulation
  • Clearing Plans of Correction (POCs)
  • Reporting Requirements
  • Timely response to CCL when communication is engaged
LPA was advised that there were five (5) residents in care, one (1) of which is on hospice.

At approximately 10:05 AM LPA and caregiver/DFR conducted a wellness and safety walk-through of facility, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and well organized. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. DFR was reminded of the mandate to label foods in airtight containers with the date they are removed from commercial packaging.

A fire extinguisher in the kitchen was last serviced on 2/16/2024 and observed to be fully charged, DRF was advised to have the device re-inspected or have a new device purchased with the receipt taped to the new extinguisher. Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well maintained and the back yard pool is fenced and secured as required by regulation.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 07/29/2025
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Continued for LIC809

There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in a closet in hallway.

At approximately 11:00 AM, five (5) staff files were reviewed and two (2) of five (5) were found incomplete with S1 having expired 1st aid (and CPR), S2 missing a MD health screening (LIC503) and S3 missing evidence of current 1st aid (and CPR) training. Type B violation issued with a plan of correction to attain missing documents by Friday 08/29/2025



Five (5) of 5 Resident files were reviewed and 5 of 5 were found to have all required documentation including recently attained Consents for Emergency Medical Treatment (LIC627C)

DRF advised LPA that a non-hospice resident expired May 16, 2025 but Community Care Licensing (CCL) has no evidence of an incident report submitted to CCL for the hospital admission on May 14th, 2025 or for the death and death report. Licensee was advised via phone that these two documents should be submitted to CCL along with a death certificate once received. In addition, licensee was advised by phone that not a single incident report is documented at CCL for items like hospital admissions, notification of hospice services, non-payment of resident fees etc.

Finally licensee was contacted by phone to make her aware that Triune, INC (4299104) not good standing with the Franchise Tax Board (FTB). Licensee indicated she had made efforts without success to reach out to FTB. Licensee was made aware that that CCL will need evidence of her efforts (email or letter or payment plan etc) of Triune, INC resuming good standing with FTB by Wednesday August 6th, 2025 by end of business day or face the potential of citation and financial penalties from CCL. In addition, licensee was notified that licensing fees of $742.00 are due and the PIN number was given to DRF/caregiver during today's inspection. In addition, FTB was provided Technical Support Program support brochure to share with licensee.

Updated Liability insurance was obtained by LPA today.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Martha Reyes (DFR) in person and Licensee Madonna Martinez by phone and and Appeal rights were given.






NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/29/2025 01:31 PM - It Cannot Be Edited


Created By: Star Stevenson On 07/29/2025 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87412(a)

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87412(a) - Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidence by:
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Licensee to submit evidence of 1st aid (CPR) training for S1 and S3 and evidence of a health screening (LIC503) for S2 by 08/29/2025
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Based on observation and record review the licensee did not comply with section cited in 3 out of 5 personnel records as evidence of messing 1st aid training and health screening which poses a potential health, safety or personal rights risk to persons 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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