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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803895
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:56:10 AM

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
04/18/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240418140944
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:
06/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Madonna MartinezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide resident medical attention in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, statements were taken from witnesses and staff, documents were obtained and reviewed and site visits made to the facility. The following determinations are made: Resident (R1) died at the facility on 03/25/2024 of cardiopulmonary arrest; R1 was elderly and suffered numerous serious medical conditions; Records indicate that staff on duty 03/25/2024 had received required training and responded appropriately when R1 became non responsive; Available records suggest that the staff provided a timely response when R1 became non responsive and that they took appropriate action by initiating CPR and calling 911; R1's Conservator has stated that Conservator believes the staff have taken good care of R1 and that the staff took timely action in response to R1's medical episode. Although the allegation may be true, based on records and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.

Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
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.
LIC9099 (FAS) - (06/04)
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