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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:15:41 PM

Document Has Been Signed on 08/02/2023 12:15 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:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Madonna Martinez, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced at the facility for the purpose of opening an initial complaint, regarding personal rights. LPA met with Administrator Madonna Martinez.

During the course of investigation LPA observed the following deficiencies.
  • Laundry room door was unlocked which contained chemicals.
  • Garage door was open which contained chemicals.
  • Side yard contained head and footboard, tree branches, cabinet and clothes rack.
  • Knife and scissors unlocked on kitchen counter-top container, cabinet with knives and chemicals unlocked.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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Document Has Been Signed on 08/02/2023 12:15 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/02/2023 at 11:42 AM
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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
87309(a)

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87309(a) STORAGE SPACE - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidence by:**
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Administrator failed to ensure chemicals and sharps were kept secured and inaccessible to residents in care. agrees to create a safety checklist for staff to complete and signage posted in the facility to ensure future compliance. Copy of safety checklist and photos of signage submitted to CCL by POC due date 8/3/2023.
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Based on observations LPA found unlocked cabinet containing chemicals accessible to residents. In addition, LPA 1 knife and 1 scissor located near the kitchen stove in a container, and unlocked laundry room and garage with cleaning supplies. This poses as an immediate health and safety risk to residents in care.
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Type B
08/10/2023
Section Cited
CCR80087(a)(c)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
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Administrator agreed to remove all items listed and send copies to CCLD no later then POC date 8/10/2023.
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Based on observation LPA observed a cabinet, head and footboard, tree branches and clothes rack located in the side yard passageway that poses a potential hazard 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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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