486803895-2-3-2026-21-AS-SSTN-DQXU58-20260203141620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 02/03/2026
Date Signed: 02/03/2026 02:16:30 PM

Document Has Been Signed on 02/03/2026 02:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MAGNOLIA GOLD HOME CARE		FACILITY NUMBER:	486803895
ADMINISTRATOR/ DIRECTOR:	MARTINEZ, MADONNA GRACE		FACILITY TYPE:	740
ADDRESS:	1515 MARIPOSA WAY		TELEPHONE:	(707) 759-5269
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 5	DATE:	02/03/2026
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Lorna Valasquez-Caregiver with Designation of Facility Responsibilty		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

NARRATIVE

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At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a quarterly Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Lorna Valasquez who has Designation of Facility Responsibility (RP). Administrator Madonna Martinez was called to advise of today's inspection. Administrator Madonna Martinez arrived at approximately 11:15 AM to assist with today's inspection

Licensing received copy of a valid Administrator's Certificate #7020245740 on 01/28/2026 with expiration date of 06/20/2027

LPA was advised that there were five (5) residents in care, two (2) of which are on hospice.

Facility is licensed for six (6) residents, five (5) of which can be non-ambulatory, one (1) bedridden and has a hospice waiver for three (3) residents. Facility was found to be a warm, comfortable temperature and without odors in each of the resident's rooms.

This facility was placed on a non-compliance (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in that NCC meeting on 06/26/2024 were:

Administrator Duties and Qualifications
Active Administrator in place for facility oversight per regulation
Clearing Plans of Correction (POCs)
Reporting Requirements
Timely response to CCL when communication is engaged

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MAGNOLIA GOLD HOME CARE	FACILITY NUMBER: 486803895
	VISIT DATE: 02/03/2026

NARRATIVE

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Continued from LIC809

Administrator was again advised that licensee Triune,INC continues to be in suspended status with the Franchise Tax Board (FTB). In addition LPA advised licensee that the department has not received recent responses from the licensee regarding their efforts to get in good standing with the FTB and that this was in violation of the NCC goal of Magnolia Gold Home Care having more, "Timely responses with Community Care Licensing (CCL) when communication is engaged"

At approximately 11:15 AM four(4) of 4 staff files were reviewed and had all required documentation including evidence of 40 hours of training within their 1st four weeks of employment.

At approximately 12:45 AM, five (5) of 5 resident files were reviewed and new resident R2 was noted to be missing signed Admissions Agreement, Pre-placement Appraisal and Consent for Emergency Medical Treatment with facility working with niece to secure. Longer term resident R1 was noted to need facility Appraisal Needs and Service and Pre-placement appraisal. A Type B citation for Violation of CCR 87506(a) Resident Records is being issued today.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed Licensee Madonna Martinez by phone and and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/03/2026 02:16 PM - It Cannot Be Edited

Created By: Star Stevenson On 02/03/2026 at 10:45 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: 02/03/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/13/2026 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that seperate complete, and current record is maintained for each resident in the facility...available to facility staff...and licensing. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee to read regulation 87506 and to submit a Pre-Placement Appraisal (LIC603) and Appraisal Needs and Service Plan (LIC625) for R1 and a Admissions Agreement, Pre-Placement appraisal & Consent for Emergecy Medical Treatment for R2 by POC date 02/13/2026
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply in 2 out of 5 resident records.which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC809 (FAS) - (06/04)

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