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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803895
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:09:56 PM

Unsubstantiated


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
11/27/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20231127103820
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: 3DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Madonna Martinez, Administrator via phoneTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident has unexplained injuries
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nakagawa and Mutialu arrived unannounced to complete an investigation and deliver findings on the above allegation.

LPAs conducted interviews, reviewed documents, and made observations. Complaint alleges that Resident (R1) has a burn on left leg and one healing on right leg. LPA Nakagawa conducted interview with R1 who was unable to recall how the injury occurred. Department reviewed R1’s medical records and photos of the injuries and was unable to determine that R1 sustained any burns. Continued on 9099-C............
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
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)
Page: 1 of 2
Control Number 21-AS-20231127103820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2024
NARRATIVE
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Continued from 9099...

A review of medical documents and care notes indicate that R1 has a condition that can produce blisters. LPA was unable to find any evidence that R1 had received any burns .Although the allegations may be valid, or true, based upon the statements made and lack of critical documents, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

Report left at facility. No citations issued regarding this investigation.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2