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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:17:57 PM

Document Has Been Signed on 06/12/2024 12:17 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: DATE:
06/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Madonna Martinez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Regional Office Manager Carla Nuti-Martinez, Licensing Program Managers, Bethany Moellers and Kimberley Mota, Licensing Program Analysts, Julie Florio, David Leibert, and Jill Nakagawa, and Administrator, Madonna Martinez and Gwen Martinez, Licensee for Magnolia Gold.

The purpose of the informal meeting was to discuss citations for deficiencies and for failure to correct Plan of Corrections (POC) by the due date, as well as citation issued on this date for Administrator's Qualifications.

The following areas of concern were discussed:

- Administrator to ensure clearing POCs and responding to Community Care Licensing (CCL) communication requests and reporting requirements. Administrator to have a plan for qualified personnel to be the facility's designated responsible party in the absence of the Administrator.

Documents requested during informal meeting to be submitted to CCL by close of business June 14, 2024:

Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 06/12/2024 12:17 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 06/12/2024 at 10:40 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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2024
Section Cited
CCR
87405(d)(a)(1)

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87405(d)(a)(1)- (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.

This requirement is not met as evidenced by:
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Licensee to ensure that the facility has a qualified, certified RCFE Administrator on-site as required by regulation. Licensee will also have a plan to designate
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inspection, the licensee diLPAs interviews, observations and records reviewed which show that Adminstrator has not been present a sufficent number of hours to properly meet the responsibilities of operating the facility. This is an immediate risk to the health and safety of all residents in care.
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designated person listed on LIC308 to ensure continuity of care and operating regulations are met in the absence of Administrator. Submit the following documents to CCL by COB 6/14/2024: LIC500, LIC308, copy of Administrator's Certificate. Attn: LPA Florio

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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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


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: 06/12/2024
NARRATIVE
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Continued from 809....

-Licensee submit an updated LIC500 indicating staff coverage in all areas of facilities
-Licensee to submit LIC308: Designation of Facility Responsibility
-Licensee to submit copy of Administrator's Certificate for current Administrator
-Administrator to self-certify that they have read regulation 87405 by 6/14/2024.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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