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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 09/02/2021
Date Signed: 09/02/2021 06:03:59 PM

Document Has Been Signed on 09/02/2021 06:03 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
09/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Madonna Martinez, Administrator TIME COMPLETED:
06:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived to Magnolia Gold Home Care unannounced to open a complaint investigation. Upon arrival, LPA was met at the door by Individual (I1), Individual (I2), and Staff Rosalina Alvia. I1, I2, and S1 all wore masks and were providing care/assistance to residents in the facility.

LPA verified through the facility Guardian Personal Report/Roster that I1 and I2 had fingerprint clearances but were not associated to Magnolia Gold Home Care as required. Interviews and records reviewed revealed I1 & I2 began working at Magnolia Gold Home Care on 06/07/2021 and 06/09/2021 and currently live at the facility as live-in staff.

LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation. Administrator stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at Magnolia Gold Home Care, the individual must obtain a fingerprint clearance and be associated to the facility.

Report continued on LIC809-C...

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 09/02/2021
NARRATIVE
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During the visit, LPA toured and inspected the facility. The following items were observed (pictures taken):
    · 3 (32oz) organic yogurt containers, 2 dated 07/24/2021 in which the container plastic lid was expanded, and 1 yogurt observed with furry white/grey mold & film.

    · A Ziplock bag of possible lemon or citrus slices observed covered with grey/green furry mold.

    · 8 plastic containers with leftover food which was not labeled with a date.

    · Medication which was unlocked and accessible on the kitchen counter. Medication closet door observed unlocked and accessible.

    · Unlocked medication was observed pre-poured in 7-day AM/PM medication pill organizer (7 total) containers. LPA previously spoke with Administrator on 05/19/2021 during the required 1-year inspection in which LPA stated a licensed facility can not pre-pour medication. Administrator stated she understood the requirement.

    · 1 metal frame portable twin size bed in Resident (R1)'s bedroom #2, which was used for staff (S1) to sleep and rest during NOC shift. Administrator stated, due to COVID-19 concerns, she preferred staff to remain at the facility to reduce exposure. Currently, the staff room located by the front entrance of the facility is occupied by I1 & I2.




Civil penalty in the total amount of $1,000.00 was issued today for individuals (I1 and I2) who were not associated to the facility as required.

Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Administrator Madonna Martinez, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/02/2021 06:03 PM - It Cannot Be Edited


Created By: Karina Canela On 09/02/2021 at 04:48 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
87355(e)(2)

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87355 (e)(2) - Criminal Record Clearance
(e) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...
This requirement was not met as evidenced by:
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Administrator to associate I1 & I2 by POC due date 09/03/2021 by close of business.

Administrator to submit a written statement they understand the requirement and will be in future compliance by POC due date 09/08/2021 to Community Care Licensing
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Based on record review, observations, and interviews conducted: Administrator did not request a transfer of a criminal record clearance for individuals (I1 & I2) prior to working at the facility. This is an immediate safety risk to the residents in care.
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Type A
09/03/2021
Section Cited
CCR87465(h)

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87465(h)(2) Incidental Medical & Dental Care: (h) The following requirements shall apply...(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator to submit a statement they understand the regulation and facility staff will be in future compliance with regulation 87465(h)(2) to ensure the health and safety of residents in care.
POC due date 09/08/2021 to Community Care Licensing
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This requirement was not met as evidenced by:
Based on observation and interviews conducted, Administrator did not ensure medications to be kept locked and inaccessible to residents. This is an immediate health & safety risk to residents.
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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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/02/2021 06:03 PM - It Cannot Be Edited


Created By: Karina Canela On 09/02/2021 at 05:14 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
87465(h)(5)

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87465(h)(5) Incidental Medical & Dental Care: (h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Administrator to transfer medication by 09/03/2021 to original containers and submit a statement they completed this as proof to LPA....

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This requirement was not met as evidenced by:
Based on observations and interviews conducted, Administrator stated they pre-poured medication for 5 of 5 residents. This is a potential health & safety risk to residents in care.
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Administrator to train all staff on the regulation 87465(h)(5). Administrator to submit a copy of proof of training to Community Care Licensing by POC due date 09/08/2021
Proof of training to include: date, time, duration, subject, names and signatures of staff.
Type B
09/07/2021
Section Cited
CCR87555(b)(8)

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87555(b)(8) General Food Service Requirements:
(b) The following food service requirements shall apply: (8) All food shall be of good quality.
This requirement was not met as evidenced by:
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LPA asked staff to immediately throw away the spoiled food.
Administrator to submit a written plan/statement of future compliance regulation 87555(b)(8)
POC due 09/08/2021
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Based on observations, Administrator did not ensure the regulation above due to 3 yogurt containers and citrus slices observed with mold and expired dates. This 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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/02/2021 06:03 PM - It Cannot Be Edited


Created By: Karina Canela On 09/02/2021 at 05:32 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2021
Section Cited
CCR
87307(a)

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87307(a) Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Administrator to ensure staff’s portable bed in Resident (R1)’s bedroom (#2) is removed from R1’s bedroom and not to be placed in any common area or resident's bedroom. Administrator to ensure that No staff, including licensee/administrator, are sleeping in any common areas and/or in a resident's room at any time.
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This requirement was not met as evidenced by:
Based on observation and interviews conducted, Administrator did not ensure the regulation above due to allowing S1 to sleep in a metal twin bed inside resident (R1)'s bedroom (#2). This is a personal rights risk to residents (R1) in care.
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Administrator to submit pictures of R1’s bedroom in which staff’s bed is removed, as proof of correction. Administrator submit a written plan/statement of future compliance regulation 87307(a).
POC of pictures and statement due 09/08/2021

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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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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