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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:05:15 PM


Document Has Been Signed on 08/08/2023 01:05 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:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(707) 759-5269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Ethal Valenzuela, CaregiverTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Carol Fowler conducted an unannounced Case Management-Other visit. LPA was greeted at the door by caregiver Ethal Valenuela, and was granted access into the facility. Administrator was unavailable. The purpose of this Case Management-Other visit is to follow up and conduct interviews pertaining to complaint control number 21-AS-20230801082339 received on 08/01/2023.

During the Case Management-Other visit, LPA interviewed two staff (S1) Staff 1 and (S2) Staff 2 and received contact information for two additional staff (S3) Staff 3 and (S4) Staff 4.

No deficiencies were observed or cited during today's Case Management-Other visit. Exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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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