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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 11/04/2025
Date Signed: 11/04/2025 02:09:15 PM

Document Has Been Signed on 11/04/2025 02:09 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: 4DATE:
11/04/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:DFR caregiver Martha ReyesTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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At approximately 11:30 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a quarterly 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.
LPA was advised that there were five (4) residents in care, one (1) of which is on hospice.


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

DFR was advised that on 08/27/2025 and again on 10/13/2025, LPA left voice mail messages with licensee that an update was needed as to the status of Triune, INC with the Franchise Tax Board (FTB). LPA advised DFR that Triune,INC is currently indicated as in suspended status with the FTB. In addition LPA advised DFR That this LPA did not receive a update response from the licensee regarding their efforts with the FTB and that this was in violation of the NCC goal of Magnolia Gold Home Care having more, "Timely responses with CCL when communication is engaged"

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2025
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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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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Document Has Been Signed on 11/04/2025 02:09 PM - It Cannot Be Edited


Created By: Star Stevenson On 11/04/2025 at 12:31 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: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
HSC
1569.625(b)(1)

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HSC 1569.625(b)(1) The department shall...require 40 hours of training....staff...shall complete 20 hours...including 6 hours of dementia care...4 hours of postural supports, restricted health conditions, hospice care...the remaining 20 hours shall include 6 hours dementia care
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Licensee to provide evidence of 30 hours of required training from an outside provider in a classroom setting or on-line, as well as documented shadow training for S1 by 12/04/2025
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within 4 weeks.
This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff members 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: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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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: 11/04/2025
NARRATIVE
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Continued from LIC809

At approximately 12:00 PM, five (5) staff files were reviewed and one staff member (S1) of five (5) were found to have just ten (10) hours of the required 40 hours of education and shadow training required for all caregivers within the first four (4) weeks of work at a Residential Community For the Elderly (RCFE) (Type B violation was issued and Plan of Correction (POC) developed.) Licensee was given a copy of educational requirements for staff and volunteers at RCFEs.

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)



At approximately 1:00 PM 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. Left-over foods were observed to be labeled appropriately.

A new fire extinguisher in the kitchen purchased 08/10/2025 was observed to be fully charged, 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.

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.

LPA obtained copy of letter indicating the 2022 Income Tax Return for Triune, INC was submitted to the IRS.

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: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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