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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803895
Report Date: 02/03/2026
Date Signed: 02/03/2026 12:45:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
12/03/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20251203135942
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: DATE:
02/03/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Adminstrator Madonna MartinezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Sexual abuse
INVESTIGATION FINDINGS:
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At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings of a complaint recieved by Community Care Licensing (CCL) on 12/03/2025. LPA was met by caregiver Lorna Velasquez who has Designation of Facility Responsibilty (RP). RP called Administrator Madonna Martinez who arrived at approximately 11:30 AM to assist with today's report findings.

During the investigation, the Department requested and reviewed documents, conducted interviews and made observations. An alligation of sexual abuse of Resident (R1) by staff member (S1) was received, in which it was alleged that S1 had exposing themselves alongside the bed of R1 and within direct view of R1.

A medical professional witness (W1) observed on 12/01/2025 between 8:30 AM and 9:15 AM, staff (S1) facing R1 with their pants down below their buttocks. W1 informed the department, it appeared S1 was stroking their gentital area, W1 was able to gain the attention of S1 who pulled up their pants. W1 exited the faciltiy and reported the incident to their manager. Based on the departments interviews, record review and obtained police report, there is a preponderance of evidence that S1 exposed their genitals to R1 and the allgation of sexual abuse is SUBSTANTIATED.
Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20251203135942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIC9099

A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

A Plan of Correction (POC) is being issued today for a Type A violation of Health and Safety Code (HSC) 1569.269(a)(10) Enumerated Rights.

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251203135942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2026
Section Cited
HSC
1569.269(a)(10)
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HSC:1569.269 Enumerated Rights;severabiltiy (a) Residents of RCFE shall have all the following rights: (10) To be free from neglect, finacial exploitation, involuntary seculsion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Licensee agrees to review regulation Health and Safety Code (HSC) 1569.269(a)(1) by 02/05/2026 and conduct a training with the staff on current LIC500 personel roster and submit self-certification that the training has been completed by 02/13/2026
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This requirement has not been met by evidence by:
Based on interviews wtih residents and care partners a prepondrance of evidence has deemed that R1 was subject to sexual abuse.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3