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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 03/04/2022
Date Signed: 03/04/2022 06:16:03 PM

Document Has Been Signed on 03/04/2022 06:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Madonna Martinez, AdministratorTIME COMPLETED:
06:26 PM
NARRATIVE
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LPA Canela arrived at Magnolia Gold Home Care for the purpose of addressing deficiencies discovered during a complaint investigation. LPA met with Madonna Martinez, Administrator.

During the investigation it was determined that Resident (R1) resided in bedroom which is not approved for bedridden residents. R1's physician report (LIC 602) indicates R1's ambulatory status is bedridden. Magnolia Gold Home Care is approved by the Fairfield Fire Department for 1 bedridden resident in master bedroom only. R1 with an bedridden ambulatory status staying in an non-bedridden approved bedroom is a fire clearance violation.

Additionally during today's inspection, LPA observed Individual (I1) in the kitchen near resident's food. Staff S1 was observed assisting a resident in the bathroom and S2 was observed contacting Administrator and later in resident hallway assisting S1. I1 stated it was their first day "shadowing" training. Administrator arrived later and stated I1 does not work at Magnolia Gold Home, I1 was waiting for Administrator. LPA confirmed with the facility's personnel roster printed 03/04/2022 that I1 is finger print cleared but not associated as required.

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.

Licensee stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at a licensed facility, 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: 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.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 03/04/2022 06:16 PM - It Cannot Be Edited


Created By: Karina Canela On 03/04/2022 at 12:59 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2022
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance: (a)All facilities shall maintain a fire clearance approved by the city, county,... fire department...Prior to accepting or retaining...the following ... the applicant or licensee shall notify the licensing agency & obtain an appropriate fire clearance approved by the... fire department...(2) Bedridden persons
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Administrator to submit a statement that they understand the regulation and shall be in future compliance. POC due date 03/11/2022 to CCL
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This requirement was not met as evidenced by: Based on observation, interviews, and record review - Administrator did not ensure the regulation above due to having bedridden resident (R1) in a non-ambulatory bedroom (not approved for bedridden residents). This is an immediate health & safety risk to residents in care.
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*** An immediate Civil Penalty in the amount of $500 was assessed.
Type A
03/05/2022
Section Cited
CCR87465(h)(2)

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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. This requirement was not met as evidenced by:
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Staff removed S1's medication and locked during the visit. Administrator to submit documentation of staff training on regulation 87465(h)(2) 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 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: 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


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, 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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Additionally, during the inspection LPA observed Staff (S1)'s personal belongings including clothing and 9 bottles of medication (over-thecounter and prescribed) and a 7-day medication pill organizer (morning, noon, evening, and bedtime) with pills. The medication was observed unlocked in Resident (R1)'s bedroom closet. LPA explained staff can not have their personal belongings stored in resident's bedrooms. S1 stated she understood.

During inspection visit dated 09/02/2021, LPA explained and cited for unlocked & accessible medications and unassociated individual in the facility.

Additionally, LPA observed residents (R1 & R2) with half bed rails on their beds. Records reviewed did not show R 1 & R2 have prescriptions for half bed rail use for assistance with mobility (postural support).


Immediate Civil Penalties in the total amount of $1,100 were assessed today:
  • $500 for a fire clearance violation.
  • $100 for an unassociated individual.
  • $250 for a repeated violation of an unassociated individual present at the facility.
  • $250 for a repeated violation of unlocked/accessible medication.



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: 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
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/04/2022 06:16 PM - It Cannot Be Edited


Created By: Karina Canela On 03/04/2022 at 04:31 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance - (e)All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Administrator to associate I1 prior to I1 returning to the facility or begining work. Administrator to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 03/11/2022 to Community Care Licensing
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Based on record review, observation, and interviews conducted: Administrator did not assocaitate individual (I1) prior to working, residing or being present in the facility.
This is a potential safety and personal rights risk to the residents in care.
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**Civil Penalty assessed in the amount of $100.00
Type B
03/11/2022
Section Cited
CCR87608(a)(5)(A)

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87608 Postural Supports- (a)... Postural supports may be used under the following conditions. (5)... (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement was not met as evidenced by:
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Administrator to obtain and submit copies of physician's orders for half bed rails for R1 & R2. Copies to be submitted to CCL to clear the citation by POC due date 3/11/22
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Based on LPA's observation and records reviewed, residents (R1 & R2) were observed with half bed rails and the facility does not have prescriptions from the resident's doctors. Administrator did not ensure residents had prescriptions prior to the use of half bed rails. This is a potential safety and personal rights 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: 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


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/04/2022 06:16 PM - It Cannot Be Edited


Created By: Karina Canela On 03/04/2022 at 05:17 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87999

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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: (13) To have access to individual storage space for private use. This requirement was not met as evidenced by:
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Administrator to remove all of staff's personal belongings stored in R1's bedroom or any other resident bedroom. Administrator to submit pictures as proof of correction and staff training on resident's personal rights reg 87468.1 with date, time, duration, subject, staff signatures and names of attendance.
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Based on interviews and observations, Administrator did not ensure the above regulation due to Staff (S1)'s personal belongings were stored in R1's bedroom closet. This is a potential personal rights violation to residents in care
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Pictures and staff training to be submitted by POC due date 3/11/22 to clear the citation.

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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: 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


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