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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
486803895
Report Date:
04/09/2024
Date Signed:
04/23/2024 01:18:23 PM
Substantiated
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2024
and conducted by Evaluator
David Leibert
COMPLAINT CONTROL NUMBER:
21-AS-20240322152816
FACILITY NAME:
MAGNOLIA GOLD HOME CARE
FACILITY NUMBER:
486803895
ADMINISTRATOR:
MARTINEZ, MADONNA GRACE
FACILITY TYPE:
740
ADDRESS:
1515 MARIPOSA WAY
TELEPHONE:
(707) 759-5269
CITY:
FAIRFIELD
STATE:
CA
ZIP CODE:
94533
CAPACITY:
6
CENSUS:
3
DATE:
04/09/2024
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Ethel Valenzeula
TIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility doesn’t have an administrator on the premises
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*****This is an amended version of the original report************
The findings on this complaint are amended from UNSUBSTANTIATED to SUBSTANTIATED. A new LIC9099 (Complaint Investigation Report) now supersedes this document.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME
:
Carla Martinez
LICENSING EVALUATOR NAME
:
David Leibert
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.
LIC9099
(FAS) - (06/04)
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