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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 05/05/2026
Date Signed: 05/05/2026 02:13:28 PM

Document Has Been Signed on 05/05/2026 02:13 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 CAREFACILITY NUMBER:
486803895
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
05/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:House Manager-Gwen Martinez and Lorna Valasquez RP TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a required annual inspection and quarterly Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Lorna Valasquez who has Designation of Facility Responsibility (RP). House Manager Gwen Martinez was advise of today's inspection. House Manager arrived at approximately 10:15 AM to further assist with today's inspection.

LPA was advised that there were four (4) residents in care, all of which were present during today's inspection.

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.

This facility was placed on a Non-Compliance Conference (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: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2026
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: 05/05/2026
NARRATIVE
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Continued from LIC809

House manager Gwen Martinez was again, for the third time, 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 updates on 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"; a concern that was raised during the last NCC inspection.

At approximately 10:45 AM a tour of the facility was conducted and facility was found to be clean and well organized, and a comfortable temperature and without odors. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Water temperature in 2 of 2 bathrooms measured within regulation of 105 -120 F. There was one new fire extinguisher observed to be fully charged. Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. A toilet in the back bathroom is noted to rock and be unstable and licensee is advised to make toilet secure so as to provide a stable toilet for residents to use. (Technical Advisory for CCR 87303(a))



The last Emergency/Disaster drill was held on 03/05/2026.

At approximately 11:45 AM LPA reviewed four (4) of 4 resident records and all 4 had complete records except resident (R1) was noted to be missing an annual health assessment. A discussion with House Manager had House Manager calling R1's responsible party to request copies of the numerous professional assessments R1 has had over the last year so as to be in compliance with CCR 87463(h)(1) of Resident Records/Incident Report

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2026 02:13 PM - It Cannot Be Edited


Created By: Star Stevenson On 05/05/2026 at 12:48 PM
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: 05/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in two (2) out of four (4) record of medication administration which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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Licensee to provide evidence of training for staff helping with medicine administration of the need to carefully document when a medicines length of timed administration has been met, removal of records of medicines that are no longer being given and the importance of providing a real time AM vs PM vs twice a day record of medicined administered.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2026


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MAGNOLIA GOLD HOME CARE
FACILITY NUMBER: 486803895
VISIT DATE: 05/05/2026
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Continued from LIC809-C
At approximately 12:15 PM LPA reviewed six (6) of 6 staff files, including two (2) new staff and found all 6 to have required documentation except staff (S1) although with a clear TB test was missing a health physical and licensee is arranging to get a copy from the staff member not working today.

Facility does not handle resident P&I money.

At approximately 1:00 PM House Manager and LPA reviewed Medicine Administration and record keeping and found Medicines to be centrally stored and secure. In two (2) out of four (4) records, House manager and LPA observed instances of medicines as having been documented as having been administered but actually had been being termed out by MD order and not in facility, as well as a second instance in which a medicine was ordered every other day and blister packed as such, but was documented as having been given everyday. A type B citation for violation of CCR 87465(c)(2) Incidental Medical and Dental is levied and Plan of Correction (POC) issued.

Licensee is asked to provide the following documents by 06/04/2026 to update the facility file including:
1) Updated LIC 308 Designation of Facility Responsibility (1 person per form)
2)Copy of updated Liability Insurance
3)LIC 9020 Resident Roster
4)LIC 500 Updated Personnel roster
5) Updated and signed LIC 610E Emergency Disaster Plan
6)Update Lease Agreement or Deed

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 RP Lorna Valasquez and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC809 (FAS) - (06/04)
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