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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:12:12 PM

Document Has Been Signed on 04/09/2024 12:12 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/
DIRECTOR:		MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
04/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Madonna Martinez via phoneTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced to conduct an investigation. There were 2 care staff and 3 residents at the time of inspection.

Facility was found to be clean and well organized. It was a comfortable temperature. Residents were clean and dressed appropriately. There was an ample supply of hygiene supplies for residents' care. There was also an ample supply of perishable and non-perishable food as required by Title 22. Staff were reminded to seal and date food to safeguard quality and freshness.

LPAs reviewed resident records and found no current orders for hospital beds, bed rails or gait belts for 2 of 3 residents.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 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 a copy of this report along with appeal rights were emailed to the Administrator due to printer issues.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 12:12 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 04/09/2024 at 11:11 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
87608(a)(3)

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Based on the individual's pre-admission appraisal....(3) a written order from a physician...order. This is evidenced by:
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Administrator to supply Dept. with proof of doctors' orders for residents use of bedrails by 4/10/24, end of business day.
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Based on review of residents' records there was no written order by physician for 1/2 bed rail which poses a potential risk to the health and safety of 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:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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