Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
63% occupied
Based on a March 2026 inspection.
Occupancy rate over time
Inspection Report
Follow-Up
Census: 92
Capacity: 146
Deficiencies: 1
Date: Mar 27, 2026
Visit Reason
The inspection was an unannounced case management follow-up visit to review self-reported medication error incidents submitted on 2026-03-24.
Findings
The inspection found that medication errors occurred where staff member S1 gave the wrong medications to residents R1 and R2. Both residents were monitored and had no adverse effects. The facility was cited for failure to assist residents properly with self-administered medications.
Deficiencies (1)
CCR 87465(a)(5) Incidental Medical and Dental Care: The licensee failed to assist residents with self-administered medications as required, evidenced by medication errors involving residents R1 and R2.
Report Facts
Census: 92
Total Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Soriano | Executive Director | Interviewed regarding medication error incidents |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 146
Deficiencies: 0
Date: Jan 30, 2026
Visit Reason
The visit was an unannounced Case Management Investigation regarding three separate incidents self-reported by the facility involving theft and alleged caregiver misconduct.
Complaint Details
The investigation involved three incidents: theft/loss and recovery of a resident's purse, an allegation of a caregiver shaking a resident and telling them to shut up, and a report of missing money from a resident's wallet. Some residents were unable to identify involved persons. Internal investigations and police reports were initiated.
Findings
No deficiencies were found at the time of the investigation and no citations were issued. The facility and Community Care Licensing will continue to investigate the reported incidents.
Report Facts
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Soriano | Administrator | Met with Licensing Program Analyst during investigation and involved in incident reporting and internal investigations |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced Case Management Investigation |
Inspection Report
Census: 86
Capacity: 146
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The visit was an unannounced Case Management - Incident Visit to follow up on a self-reported incident involving a resident and staff interaction reported on 12/12/2025.
Findings
No evidence was found to corroborate abuse or neglect. The facility had no deficiencies or citations at the time of inspection. Staff will be trained to improve communication with residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Soriano | Administrator | Met with Licensing Program Analyst during the inspection and involved in incident investigation. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced inspection visit. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 146
Deficiencies: 0
Date: Dec 11, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff chemically restrained residents by administering PRN medications to keep them calm.
Complaint Details
The complaint alleged that staff chemically restrained residents by administering PRN medications as instructed by the Executive Director. The allegation was found unsubstantiated after review of medication administration records and staff interviews.
Findings
The investigation included interviews and medication record reviews which found no irregularities. The allegation that staff chemically restrained residents was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Memory care residents reviewed: 8
Memory care residents receiving PRN medications: 30
Residents receiving PRN pain relievers: 5
Residents receiving other PRN pain medication: 2
Residents receiving PRN medication for anxiety: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kristine Soriano | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 146
Deficiencies: 0
Date: Dec 11, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff were not ensuring a resident was showered as required by the care plan.
Complaint Details
The complaint alleged staff were not ensuring a resident was showered as per the care plan. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the resident's roommate sometimes refused caregiver access to assist with showering. The resident's responsible party confirmed showers were provided, though not regularly, and no medical concerns were noted. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 146
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristine Soriano | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 146
Deficiencies: 1
Date: Oct 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were billing for services not rendered and that staff did not safeguard resident belongings.
Complaint Details
The complaint investigation was substantiated for billing for services not rendered and unsubstantiated for failure to safeguard resident belongings. The complaint control number is 21-AS-20250804125148.
Findings
The allegation that staff were billing for services not rendered was substantiated based on observations and document reviews showing that resident R1 did not receive the billed care. The allegation that staff did not safeguard resident belongings was unsubstantiated due to lack of evidence and resident interviews.
Deficiencies (1)
Health and Safety Code 1569.657(a): Licensee failed to provide additional services corresponding to a rate increase due to a change in level of care. This posed an immediate health, safety, and personal rights risk to residents.
Report Facts
Capacity: 146
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Capacity: 146
Deficiencies: 0
Date: Oct 2, 2025
Visit Reason
The case management inspection was conducted to meet with the new Administrator and discuss reporting guidelines, other areas of concern, and open complaint investigations.
Findings
No deficiencies were cited at the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Soriano | Executive Director | Met with during the case management inspection. |
| Gina Lapid | Care Coordinator for Memory Care | Met with during the case management inspection. |
| Jhoanna Tagle-Serrano | Care Coordinator for Assisted Living | Met with during the case management inspection. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-04-07 regarding inadequate supervision, unmet care needs, improper medication dispensing, and unqualified staff dispensing medication at Magnolia Court.
Complaint Details
The complaint alleged inadequate supervision, unmet care needs, improper medication dispensing, and unqualified staff dispensing medication. After review and multiple observations, these allegations were found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found all allegations unsubstantiated based on observations, staff schedules, resident care plans, medication records, and staff training documentation. The facility was observed to provide adequate supervision, meet residents' care needs, and ensure medications were dispensed properly by qualified staff.
Report Facts
Capacity: 146
Census: 80
Medication accuracy: 5
Resident care plans reviewed: 5
Resident interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Candice Moses | Administrator | Facility administrator met during investigation |
| Gina Lapid | Memory Care Director | Met during investigation and provided information |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on a self-reported incident involving a resident elopement.
Complaint Details
The visit was triggered by a self-reported incident where a resident diagnosed with dementia eloped from the facility on 07/06/2025. The complaint was substantiated with a deficiency cited for absence of supervision.
Findings
The facility failed to provide adequate supervision to a resident with dementia who eloped from the facility, resulting in a civil penalty for absence of supervision and zero tolerance violation.
Deficiencies (1)
CCR 87411(a) Personnel Requirements - Facility personnel were insufficient to meet resident needs, resulting in failure to supervise a resident who eloped. This absence of supervision posed an immediate risk to resident health, safety, and rights.
Report Facts
Civil Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Moses | Administrator | Met during inspection and named in incident report |
| Mindy Melendez | Chief Strategy Officer | Met during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted inspection and authored report |
| Kimberley Mota | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 82
Capacity: 146
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
The facility was found to be clean, orderly, and compliant with Title 22 requirements. Resident and personnel records were well-organized and complete. Fire alarms were operational and fire drills were conducted for all shifts. Medication management systems and outdoor areas were satisfactory. No citations were issued.
Report Facts
Medication supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Moses | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 146
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-03-06 regarding insufficient food service, lack of dignity in staff-resident relationships, and failure to provide activities for all residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient food service, residents not accorded dignity by staff, and lack of activities for all residents. Evidence did not support these claims.
Findings
The investigation found no evidence to substantiate the allegations. Food service was adequate with appropriate meal options and resident monitoring. Staff treated residents with dignity and respect. Activities were provided regularly with good resident participation.
Report Facts
Facility Capacity: 146
Resident Census: 84
Residents Participating in Activity: 22
Total Residents in Activity Area: 28
Residents Requiring Special Diets: 3
Family and Staff Interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Moses | Administrator | Met with Licensing Program Analyst during investigation |
| Gina Lapid | Memory Care Director | Provided information about meal service and resident care during investigation |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 146
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including residents not being provided proper nutritional needs, staff not ensuring residents' grooming needs are met, and lack of supervision resulting in falls.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: improper nutrition, unmet grooming needs, and lack of supervision resulting in falls. The investigation included observations, interviews, and record reviews conducted on 01/09/2025 and 01/30/2025.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Residents were provided proper nutrition with appropriate meal accommodations, grooming needs were met with residents observed clean and appropriately dressed, and supervision was adequate with staff regularly checking residents and no citations issued.
Report Facts
Capacity: 146
Census: 75
Residents requiring special diets: 5
Memory Care residents observed: 15
Memory Care residents observed: 20
Staff per shift: 3
Medication technician per shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Moses | Administrator | Met during investigation and discussed allegations |
| Gina Lapid | Memory Care Director | Met during investigation and discussed allegations |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff inappropriately posted residents on personal social media.
Complaint Details
The complaint alleging inappropriate posting of residents on personal social media was substantiated based on interviews, record reviews, and photographic evidence.
Findings
The investigation substantiated that staff violated residents' personal rights by posting resident photos on Facebook without consent, posing a potential health, safety, and personal rights risk to residents.
Deficiencies (1)
CCR 87468.2(a)(1) requires residents to have a reasonable level of personal privacy. Staff posted resident photos on the internet without consent, violating this right and posing a potential health and safety risk.
Report Facts
Facility Capacity: 146
Resident Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Moses | Administrator | Met during investigation and exit interview |
| Jill Nakagawa | Licensing Evaluator | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff were not meeting residents' care needs.
Complaint Details
The complaint alleged that staff were not meeting residents' care needs. The allegation was unsubstantiated after review of records, observations, and interviews.
Findings
The investigation found that staff attempted to provide regular continence care, showers, bed baths, and repositioning as per doctor's orders. Although the resident could be combative or refuse care, and additional staff was used to facilitate care, there was no preponderance of evidence to prove the alleged violation, so the complaint was unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation. |
| Candice Moses | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that due to a lack of staff, residents were not assisted with feeding and not showered timely.
Complaint Details
The complaint investigation was substantiated for the allegation that residents were not assisted with feeding due to lack of staff. The allegation that residents were not showered timely was unsubstantiated.
Findings
The allegation regarding lack of assistance with feeding was substantiated based on observations and interviews showing residents with dementia were not supervised during meals and food was served improperly. The allegation regarding untimely showers was unsubstantiated as records and observations showed residents were showered according to care plans.
Deficiencies (1)
CCR 87468.2(a)(4) Personal Rights of Residents: The licensee failed to ensure residents were assisted with feeding, resulting in an immediate health and safety and personal rights risk.
Report Facts
Facility Capacity: 146
Census: 80
Residents requiring feeding assistance: 2
Residents requiring re-direction or assistance with eating: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Candice Moses | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 146
Deficiencies: 1
Date: Sep 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-23 regarding resident care and visitation issues at Magnolia Court.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff stopped visitation without proper authorization. Other allegations about resident injuries, unmet care needs, rough handling, and privacy violations were found unsubstantiated due to lack of evidence.
Findings
One allegation regarding facility staff not allowing a resident to have visitors was substantiated due to stopping visitation without proper documentation. Other allegations related to resident injuries, unmet care needs, rough handling, and privacy violations were unsubstantiated based on interviews and record reviews.
Deficiencies (1)
CCR 87468.1(a)(11) Personal Rights of Residents in All Facilities: The licensee did not comply with the regulation by stopping visitation at the direction of a resident’s responsible party without documentation, posing an immediate personal rights risk.
Report Facts
Capacity: 146
Census: 77
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Candice Moses | Administrator | Met with the evaluator during the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 146
Deficiencies: 0
Date: Sep 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not follow protocols to prevent the spread of illness.
Complaint Details
The complaint alleged that Covid positive cases were not reported and positive residents were walking around. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility reported a Covid outbreak timely and isolated positive residents except one Memory Care resident who required frequent redirection. There was insufficient evidence to substantiate the complaint, and no deficiencies were cited.
Report Facts
Capacity: 146
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Evaluator | Conducted the complaint investigation |
| Candice Moses | Administrator | Met with evaluator during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 146
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate supervision to a resident in care.
Complaint Details
The complaint alleged that a staff member brought their family member to the facility who entered resident rooms without permission and rummaged through them. Multiple interviews were conducted but the allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegation that staff allowed a family member to enter resident rooms without permission. The complaint was determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 146
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Mike Carpenter | Interim Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 75
Capacity: 146
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
The inspection was an unannounced Case Management visit to verify that an individual who was issued an exclusion was not present at the facility.
Findings
No deficiencies were cited during the inspection. The excluded individual was confirmed not to be working at or present on the premises.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced Case Management inspection. |
| Gina Lapid | Memory Care Director | Contacted Business Office Manager to verify exclusion status. |
| Jennifer Roldan | Business Office Manager | Verified that the excluded individual was not working at or on site. |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-06-17 regarding staff hitting residents and staff screaming at residents.
Complaint Details
The complaint investigation was unsubstantiated. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The allegations that staff hit residents and screamed at residents were found to be unsubstantiated due to inconsistent statements and lack of corroborating evidence.
Report Facts
Facility Capacity: 146
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-28 regarding inadequate staff supervision leading to residents leaving the facility and resident-on-resident assaults.
Complaint Details
The complaint investigation was substantiated for inadequate supervision resulting in residents leaving the facility. The allegations regarding inadequate information to responsible parties and resident-on-resident assaults due to lack of supervision were unsubstantiated.
Findings
The complaint that staff did not provide adequate supervision resulting in residents leaving the facility was substantiated with deficiencies cited. The allegations that staff did not provide adequate information to responsible parties and that resident-on-resident assaults occurred due to lack of supervision were unsubstantiated. The facility implemented care interventions and notified families as appropriate.
Deficiencies (1)
CCR 87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials were not met as resident R1 eloped from the facility without supervision. R1 is diagnosed with dementia and requires special supervision for confusion and wander risk, posing an immediate health and safety risk.
Report Facts
Facility Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Evaluator | Conducted the complaint investigation |
| Mike Chatman | Acting Administrator | Met with Licensing Program Analysts during investigation |
| Yolanda Harrell | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 2
Date: Jul 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-06-10 regarding staff blocking facility exit doors and failure to ensure residents' hygiene needs were met.
Complaint Details
The complaint investigation was substantiated for allegations that staff blocked facility exit doors and failed to ensure residents' hygiene needs were met. Other allegations about safe environment and dignity were unsubstantiated due to lack of evidence.
Findings
The investigation substantiated the allegations that staff blocked facility exit doors with furniture in the memory care unit and failed to ensure timely hygiene services for residents, including leaving a resident in soiled clothing. Other allegations regarding safe environment and dignity were unsubstantiated.
Deficiencies (2)
CCR 87303(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. Staff were observed blocking memory care unit exit doors with furniture, posing an immediate health and safety risk.
CCR 87464(f) Basic services shall include care and supervision as described in Health and Safety Code section 1569.2(c). A resident was found left in soiled clothing and residents were observed being left in soiled clothing without timely hygiene care.
Report Facts
Facility Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Evaluator | Conducted the complaint investigation and signed the report |
| Kimberley Mota | Supervisor | Supervised the complaint investigation |
| Mike Chatman | Acting Administrator | Met with evaluators during the investigation |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of staff mismanaging residents' medication and narcotics theft.
Complaint Details
The complaint alleged staff mismanaged residents' medication and that a staff member took narcotics from the facility. The allegation was found to be unsubstantiated after review of medication records, observations, and interviews.
Findings
The investigation found that medication supply, records, and handling were properly managed with no evidence supporting the allegation. The complaint was determined to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Facility Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Evaluator | Conducted the complaint investigation |
| Mike Chatman | Acting Administrator | Met with Licensing Program Analysts during investigation |
| Kimberley Mota | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-06-26 regarding inappropriate staff behavior and medication administration at Magnolia Court.
Complaint Details
The complaint alleged that facility staff spoke inappropriately to residents, restrained residents in a rough manner, and did not administer medications as prescribed, including an allegation of staff taking narcotics. The investigation found these allegations unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found insufficient evidence to substantiate allegations that staff spoke inappropriately to residents, restrained residents roughly, or failed to administer medications as prescribed. Medication handling and security protocols were observed to be properly followed.
Report Facts
Facility Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Evaluator | Conducted the complaint investigation |
| Kimberley Mota | Supervisor | Supervised the complaint investigation |
| Mike Chatman | Acting Administrator | Met with Licensing Program Analysts during investigation |
Inspection Report
Census: 71
Capacity: 146
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
The visit was an unannounced Case Management - Health and Safety Check regarding a fire incident that occurred on 2024-06-26.
Findings
The Licensing Program Analyst toured the facility, interviewed staff and clients, and reviewed the updated Smoking Policy and fire prevention process. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Chatman | Acting Executive Director | Met with during the inspection visit. |
Inspection Report
Census: 71
Capacity: 146
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The visit was an unannounced Case Management follow-up to verify Administrator qualifications and the status of assigning a designated Administrator for the care facility.
Findings
The Acting Administrator provided proof of re-certification, and the Licensee is determining the final candidate for the Administrator position. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Chatman | Acting Administrator | Named in relation to Administrator qualifications follow-up |
| Grace Montemayor | Resident Service Director | Named in relation to Administrator qualifications follow-up |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 146
Deficiencies: 2
Date: Jun 20, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-05-16 regarding staff training, timely resident care, and medication security.
Complaint Details
The complaint investigation was substantiated for allegations that staff were not properly trained and did not attend to resident care needs in a timely manner. The allegation that centrally stored medications were accessible to residents was unsubstantiated.
Findings
The investigation substantiated that staff were not properly trained and failed to respond to resident care needs in a timely manner, with call bell response times between 1-3 hours. The allegation that centrally stored medications were accessible to residents was found to be unsubstantiated.
Deficiencies (2)
CCR 87411(a) Facility personnel were insufficiently trained and failed to respond appropriately to call bell system, resulting in delayed resident care. Call bell response times ranged from 1 to 3 hours, posing an immediate risk to resident health and safety.
HSC 1569.625(b)(1) Staff did not complete required training including dementia care and hoyer lift before working independently. Twelve caregiving staff received hoyer lift training after resident R1 required such assistance, creating a potential health and safety risk.
Report Facts
Census: 71
Total Capacity: 146
Number of caregiving staff trained on hoyer lift: 12
Call bell response time: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Evaluator | Conducted the complaint investigation |
| Grace Montemayor | Resident Service Director | Met with Licensing Program Analysts during investigation |
| Mike Chatman | Acting Administrator | Met with Licensing Program Analysts during investigation |
| Yolanda Harrell | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 74
Capacity: 146
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Inspection conducted to evaluate compliance with licensing requirements for assisted living and memory care.
Findings
The facility was found to be clean, orderly, and compliant with regulations. No deficiencies or citations were issued during the inspection.
Report Facts
Fire extinguishers inspected: 10
Resident records reviewed: 5
Personnel records reviewed: 5
Medication supply: 30
Inspection Report
Complaint Investigation
Census: 84
Capacity: 146
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of neglect and lack of supervision resulting in resident falls with injuries.
Complaint Details
Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). The allegation was unsubstantiated after review of care plans, staff schedules, and interviews showed appropriate supervision and accommodations were in place.
Findings
The investigation included interviews, document reviews, and observations. The allegation was found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 146
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation inspection |
| Yolanda Harrell | Administrator | Facility administrator met with the evaluator during the inspection |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 146
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-10-03 alleging inadequate staff supervision resulting in a resident leaving the facility and inadequate information provided to a responsible party.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Farhaan Sarangi. The allegation that staff did not provide adequate supervision resulting in a resident leaving the facility was unsubstantiated. The allegation that staff did not provide adequate information to the responsible party was substantiated. The facility was educated on Title 22 regulations and a plan of correction was required.
Findings
The allegation of inadequate supervision resulting in a resident leaving the facility was unsubstantiated due to inconsistent information and lack of evidence. The allegation that staff did not provide adequate information to a responsible party was substantiated, with findings that staff did not adequately check on the resident and provided insufficient information.
Deficiencies (1)
CCR 87468.1(a)(8) Personal Rights of Residents: Staff did not adequately check on the resident and provided inadequate information to the responsible party regarding the resident's care and activities.
Report Facts
Capacity: 146
Census: 82
Deficiency count: 1
Plan of Correction Due Date: Nov 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Harrell | Administrator | Facility administrator met during inspection and named in findings |
| Farhaan Sarangi | Licensing Program Analyst | Evaluator conducting the complaint investigation |
Inspection Report
Census: 82
Capacity: 146
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced Case Management-Other inspection to deliver complaint findings and assess compliance.
Findings
No deficiencies were cited during the inspection. The Administrator was educated on the importance of regularly observing residents after a technical violation was noted regarding inadequate resident checks.
Deficiencies (1)
LIC 9102-Technical Violation: Staff did not adequately check on the resident and make observations as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Harrell | Administrator | Named in relation to the technical violation and during the inspection. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and delivered complaint findings. |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to meet a resident's care needs.
Complaint Details
The complaint alleged that the facility failed to meet a resident's care needs. The investigation found the complaint to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found no evidence to support the complaint against Magnolia Court. The allegation was determined to be unfounded and no citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Canela | Licensing Program Analyst | Conducted the complaint investigation. |
| Yolanda Harrell | Executive Director | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Annual Inspection
Census: 85
Capacity: 146
Deficiencies: 0
Date: May 23, 2023
Visit Reason
The inspection was an unannounced 1-Year Annual Inspection conducted to evaluate compliance with licensing requirements for assisted living and memory care.
Findings
The facility was found to be clean, orderly, and compliant with regulations. No deficiencies were cited during the inspection. Safety equipment and drills were up to date and conducted regularly.
Report Facts
Fire extinguisher last service date: Oct 17, 2022
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Feb 24, 2023
Visit Reason
The visit was an unannounced case management investigation regarding a self-reported incident between two residents that occurred on 2023-02-17.
Complaint Details
The investigation was related to a self-reported incident between resident R1 and resident R2 occurring on 2023-02-17. No deficiencies or citations were issued.
Findings
The facility provided documentation showing residents had been re-assessed, responsible parties notified, and care plans adjusted to support changing resident needs. No deficiencies or citations were found at the time of inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management investigation. |
| Yolanda Harrell | Administrator | Met with Licensing Program Analyst regarding the incident. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 146
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
The visit was conducted to investigate a complaint alleging that staff physically abused a resident in care.
Complaint Details
The complaint alleged staff abused a resident in care. The allegation was found to be unsubstantiated after review of medical records, interviews, and observations.
Findings
The investigation found no witnesses to the alleged abuse and conflicting explanations for a red mark on the resident's face. The allegation of staff abuse was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 146
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Walters | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Yolanda Harrell | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 146
Deficiencies: 1
Date: Nov 28, 2022
Visit Reason
The visit was conducted to investigate complaints alleging that the facility failed to seek timely medical attention based on an observed change of condition and that the facility was not following a resident's care plan.
Complaint Details
The complaint alleged that the facility failed to seek timely medical attention based on an observed change of condition and was not following resident R1's care plan. The failure to seek timely medical attention allegation was found to be unfounded. The allegation regarding not following the care plan was substantiated.
Findings
The allegation regarding failure to seek timely medical attention was found to be unfounded. The allegation that the facility was not following the resident's care plan was substantiated, with findings that staff did not follow home health instructions and failed to document notifications properly. The administrator corrected the deficiency prior to the visit by implementing communication logs and progress note auditing.
Deficiencies (1)
CCR 87464(d) Basic Services: The facility did not ensure compliance with home health agency instructions for resident R1, posing a potential health, safety, and personal rights risk. The administrator developed communication logs and a ledger for progress notes to address this issue.
Report Facts
Capacity: 146
Census: 79
Plan of Correction Due Date: Dec 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Herrell | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Katrina Walters | Licensing Evaluator | Conducted the complaint investigation |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 146
Deficiencies: 1
Date: Oct 6, 2022
Visit Reason
The visit was an unannounced case management follow-up on a self-reported incident involving a resident's un-witnessed fall and delayed medical treatment.
Complaint Details
The investigation was triggered by a self-reported incident of a resident's un-witnessed fall and delayed medical treatment. The complaint was substantiated based on records and interviews.
Findings
The facility delayed seeking medical treatment for a resident after an un-witnessed fall, posing a potential health and safety risk. Staff will undergo in-service training on when to seek emergency medical treatment.
Deficiencies (1)
CCR 87465(a)(1) Incidental Medical and Dental Care. The licensee failed to arrange or assist in arranging appropriate medical care, resulting in delayed treatment for a resident after a fall. This poses a potential health and safety risk to residents.
Report Facts
Deficiency Type: 1
Census: 80
Total Capacity: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Chapman | Operation Specialist | Met with Licensing Program Analyst during inspection and involved in care conference planning |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 146
Deficiencies: 0
Date: Sep 2, 2022
Visit Reason
The visit was an unannounced case management inspection triggered by a Report of Suspected Dependent Adult/Elder Abuse submitted by the facility regarding a theft incident reported by a resident.
Complaint Details
The complaint involved a resident reporting $200 stolen from their room on 08/19/2022. The facility's investigation found no staff matching the description given by the resident and noted the resident left their door open and wallet visible. The incident was reported to law enforcement and other relevant authorities.
Findings
The facility conducted a thorough investigation into the reported theft of $200 from a resident's room and followed their Theft and Loss policy. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Ebert | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 75
Capacity: 146
Deficiencies: 1
Date: Apr 8, 2022
Visit Reason
The inspection was an unannounced Required 1 Year annual inspection focusing on infection control at the facility.
Findings
The facility was generally clean and compliant with infection control practices; however, a deficiency was found related to unsafe storage of items accessible to residents with dementia, posing an immediate safety risk.
Deficiencies (1)
CCR 87705(f)(1) Care of Persons with Dementia - The licensee did not store medications and potentially dangerous items inaccessible to residents with dementia. Medicated salve, scissors, and mouthwash were found unlocked and accessible in two memory care residents' rooms, posing an immediate safety risk.
Report Facts
Deficiencies cited: 1
POC Due Date: Apr 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonya Tucker Tafolla | Director of Resident Care | Met with Licensing Program Analyst during inspection and exit interview |
| Katrina Walters | Licensing Evaluator | Conducted the inspection and signed the report |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 146
Deficiencies: 2
Date: Dec 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident sustaining a fracture during care and medication theft and mismanagement.
Complaint Details
The complaint investigation was initiated due to allegations that a resident sustained a fracture during care and that the facility failed to provide care resulting in injury, as well as allegations of medication theft and improper medication storage. The fracture allegation was unsubstantiated, but medication-related allegations were substantiated.
Findings
The investigation found the fracture allegation unsubstantiated due to lack of evidence. However, allegations of medication theft and improper medication storage were substantiated with multiple incidents reported. Deficiencies related to medication administration and storage were cited.
Deficiencies (2)
CCR 87465(c)(2) Incidental Medical and Dental Care. Facility reports several incidents where residents’ pain medications were replaced by other non-narcotic over-the-counter medications, posing an immediate risk to resident health.
CCR 87465(c)(5) Incidental Medical and Dental Care. Residents' medications were not stored in their originally received containers, violating storage requirements and posing an immediate risk to resident health.
Report Facts
Facility Capacity: 146
Resident Census: 78
Deficiencies cited: 2
Plan of Correction Due Date: Dec 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tonya Tucker Tafolla | Facility representative met during investigation | |
| Robin Stouder | Administrator | Facility administrator reported medication issues |
| Carla Martinez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 81
Capacity: 146
Deficiencies: 1
Date: Oct 28, 2021
Visit Reason
Licensing Program Analyst arrived unannounced to follow up on a reported incident involving an elopement by a resident whose physician ordered that the resident not leave the facility unassisted.
Findings
The investigation concluded there was a lack of supervision resulting in the resident's elopement. A $500 civil penalty was issued for lack of supervision.
Deficiencies (1)
CCR 87464(f)(1) Basic services shall include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as a resident eloped unaccompanied by staff and remained away for 30 to 40 minutes, posing an immediate risk to safety.
Report Facts
Civil Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Martinez | Supervisor | Named as supervisor in the report related to the deficiency. |
| David Leibert | Licensing Evaluator | Conducted the inspection and signed the report. |
Inspection Report
Annual Inspection
Census: 64
Capacity: 146
Deficiencies: 0
Date: May 20, 2021
Visit Reason
An unannounced Annual Required 1-year Infection Control inspection was conducted to evaluate compliance with infection control standards.
Findings
The facility was found clean, with proper COVID-19 screening and infection control measures in place. No deficiencies were cited during the inspection.
Inspection Report
Follow-Up
Census: 64
Capacity: 146
Deficiencies: 0
Date: May 20, 2021
Visit Reason
The visit was a subsequent Case Management - Incident follow-up to an incident report regarding missing cash from a resident's private residence.
Findings
The facility was unable to prove or disprove the allegation of theft by a staff member. An investigation by the police is pending. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Rasmussen | Administrator | Met during the visit and involved in the incident report follow-up. |
| Savannah Arcy | Director of Resident Services | Met during the visit and involved in the incident report follow-up. |
Inspection Report
Complaint Investigation
Capacity: 146
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
The inspection was conducted as a Case Management visit regarding a self-reported incident of alleged theft at the facility. The visit was conducted via teleconference due to COVID-19 precautions.
Complaint Details
The complaint involved a resident reporting missing cash from their private residence, allegedly taken by an individual identified as S1. The facility administrator notified law enforcement, Community Care Licensing, and the Ombudsman. The individual was terminated following the investigation.
Findings
No deficiencies were cited during the inspection. The investigation found that a resident's cash was missing and the alleged individual responsible was terminated following an investigation involving law enforcement.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Christensen | Director of Operations | Met with Licensing Program Analyst during the inspection and involved in the investigation of the alleged theft. |
| Alma Fuentez | Executive Director | Participated in the teleconference inspection and exit interview. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 146
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that facility staff did not notify a resident's authorized representative of the resident's condition and that communications to the licensee from resident representatives were not answered promptly and appropriately.
Complaint Details
The complaint was unsubstantiated. The allegations that facility staff failed to notify the resident's authorized representative and did not respond promptly to communications were not proven by a preponderance of evidence.
Findings
The investigation found conflicting information regarding notification and communication with the resident's authorized representative. Although some proof of notification was provided, there was insufficient corroborating evidence to substantiate the allegations. No deficiencies were cited during the visit.
Report Facts
Capacity: 146
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Savannah Beddell | RSD/LVN | Met with evaluator during investigation |
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