Magnolia Court

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff are billing for services not rendered.

On 10/24/2025,Licensing Program Analyst (LPA)Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation. LPA met with Jennifer Roldan, Business Office Manager for Kristine Soriano, Administrator to discuss. The complaint alleges that staff are billing for services not rendered. The reporting party RP stated that Resident R1 received a billing increase for an increase in services in mid-July, 2025. The reporting party stated that R1 is not receiving the services being billed and paid for which includes: showers twice a week, incontinence care as required, and regular housekeeping to keep the room sanitary. (Continued on 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Oct 24, 2025 · control 21-AS-20250804125148

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure adequate supervision is provided to residents in care Staff do not ensure care needs of residents are being met Staff do not ensure medications are dispensed as prescribed Licensee allows unqualified staff to dispense medication

On 7/22/2025 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue an investigation and deliver findings regarding the above allegations. LPA met with Administrator Candice Moses and Memory Care Director Gina Lapid. The complaint alleges Staff do not ensure adequate supervision is provided to residents in care. LPA observed that during visits on 3/11/2025 (11AM - 4PM), 4/1/2025 (10AM - 4PM), 4/7/2025 (3:20-4:50 PM), 5/29/2025 (10:25AM - 4:55PM), 7/17/2025 (10AM - 2:45PM) and 7/22/2025 (12:55 - 2:00PM) there appeared to be adequate supervision during the time of visit, with a majority of residents out of their rooms socializing in the common rooms; typically 20-22 of 28 residents on the days observed with one caregiver circulating in the common areas and two caregivers and a med tech providing care and medications to residents in their rooms. Based on LPA's observations and staff schedules the allegation that Staff do not ensure adequate supervision is provided to resthe state’s words, verbatim · CDSS document, Jul 22, 2025 · control 21-AS-20250407085527

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility has insufficient food service. Residents are not accorded dignity in their relationship with staff. Staff do not provide activities for all residents.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation regarding the above allegations on 3/11/2025 and 04/01/2025. LPA Nakagawa met with the Administrator Candice Moses and the Memory Care Coordinator Gina Lapid to discuss. Regarding the allegation Facility has insufficient food service: LPA toured the facility kitchen on 04/01/2025 and found an ample supply of fresh and frozen foods to supply the menu choices. The chef stated that all residents in Assisted Living and Memory Care communities are given the same multiple choices at each meal. A copy of the menus for 03/02/2025 through 04/05/2025 was provided to LPA. LPA was told by staff Memory Care Director Gina Lapid that meal service in Memory Care is brought over from the central kitchen pre-plated and served by care staff. Continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20250306150522

Allegation investigated: Residents not provided proper nutritional needs Staff does not ensure residents grooming needs are met Lack of supervision resulting in falls

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue an investigation regarding the above allegations. LPA Nakagawa met with the Administrator Candice Moses and the Memory Care Coordinator Gina Lapid to discuss. During the course of the investigation, LPA conducted unannounced inspections on 01/09/2025 and 01/30/2025, made observations, reviewed records, and interviewed staff and others. Due to no contact information, LPA was unable to obtain further information from the reporting party. It is alleged that Residents are not provided proper nutritional needs. LPA toured the facility kitchen on 01/09/2025 and found an ample supply of fresh and frozen foods to supply the menu choices which are provided to all residents: Assisted Living and Memory Care communities. Continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 30, 2025 · control 21-AS-20250109092615

Allegation investigated: Staff not meeting residents care needs

Licensing Program Analyst (LPA) Nakagawa arrived unannounced and conducted a complaint investigation regarding the allegation listed above. LPA met with Candice Moses, Administrator. The complaint alleges that staff are not meeting resident’s care needs. During the investigation LPA reviewed records, made observations and conducted interviews. LPA's record review found that resident R1 was hospitalized from 7/21/24 – 7/27/24. A review of records during this time did not reveal any concerns regarding R1’s care. On 8/13/2024 R1 was sent to ER and at that time there were concerns raised regarding hygiene care. Continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20240813153600

Allegation investigated: Due to a lack of staff, residents are not assisted with feeding

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrator Candice Moses. The complaint alleges that due to a lack of staff, residents are not assisted with feeding. LPA reviewed documents and conducted interviews which revealed that 2 of 28 residents in memory care, residents R1 and R2, require assistance with feeding. There are additional residents, R3 and R4 who require constant re-direction to eat and/or assistance in cutting their food and receiving proper utensils. Continued on 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20240826150840

Allegation investigated: Staff inappropriately posted residents on personal social media

Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegation. LPA met with Administrator Candice Moses . The allegation states that the Staff inappropriately posted residents on personal social media. Based on LPA interviews, review of records, and photos LPA obtained, the investigation has revealed that the Staff S1 violated residents’ personal rights by posting resident photos on Facebook without consent. The preponderance of evidence standard has been met, therefore the allegation that Staff inappropriately posted residents on personal social media is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached 9099-D). Continued on 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20241106125840

Allegation investigated: Facility staff are not allowing resident to have visitor(s)

LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with the new Administrator, Candice Moses. Facility staff are not allowing resident to have visitor(s) – Complaint alleges that facility staff are not allowing resident to receive visitors. Per interviews, it was confirmed that the facility stopped visitation for individuals as directed by a resident’s responsible party. No documentation was provided to allow for this action. Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Continued on 9099-D Substantiatedthe state’s words, verbatim · CDSS document, Sep 27, 2024 · control 21-AS-20240523083545

Allegation investigated: Staff did not follow protocols to prevent the spread of illness.

LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with Candice Moses, the newly appointed Administrator. Staff did not follow protocols to prevent the spread of illness – Complaint alleges that covid positive cases were not being reported and positive residents were walking around. Per interview, facility reported a Covid outbreak on 7/7//2024 to the local public health department and created a Special Incident Report for CCL on 7/8/2024. CCL received the report on 7/9/2024. Per the Special Incident Report, a third resident tested positive on 7/7/2024, which prompted the facility to report the Covid outbreak, per local public health requirements. Per interview, Covid positive residents isolated well, except one Memory Care resident who had to be redirected frequently. When the resident refused to isolate, facility staff asked them to mask and attempted to provide distance between resident and Covid negative residents who were not requthe state’s words, verbatim · CDSS document, Sep 27, 2024 · control 21-AS-20240708160837

Allegation investigated: Staff did not provide adequate supervision to resident in care

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with Mike Carpenter, Interim Administrator. Staff did not provide adequate supervision to resident in care – Complaint alleges that a staff brought their family member to the facility allowing them to go into resident rooms without permission and “rummage” through the rooms. CCL staff conducted multiple interviews but were unable to corroborate that this event happened. Although the allegation that Staff did not provide adequate supervision to resident in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 6, 2024 · control 21-AS-20240610105634

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not provide adequate supervision resulting in residents leaving facility

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties, reviewed resident and facility records and made observations during the course of the investigation. Complaint alleges staff does not provide adequate supervision resuliting in residents leaving facility. Based upon review of facility incdient reports it was found that on the evening of 5/22/2024, resident (R1) had been found out in the community unassisted. Based upon a review of R1's Physicain's Report it is indicated that R1 is diagnosed with dementia and resides in the memory care unit. In addition, review of the Preplacement Appraisal indicates that R1 required special observation/night supervision due to confusion, forgetfullness and wandering. Lastly, review indicated contracdicting information on R1's physicianthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240528094749

Allegation investigated: Staff mismanaged residents' medication

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and made observations during the course of the investigation. Complaint alleges, staff mismanaged resident's medication additionally indicating staff (S1) taking narcotics from the facility. Based on LPA spot review of medication supply and medication records, medications, narcotics and records for 3 out of 3 residents in memory care and 3 out of 3 residents in assisted living were found to be in order. During LPA observations during medication record keeping, administering and medication security protocols, LPA found that medtech staff (S2 & S3) appropriately handled medications and records. During a tour of the facility, LPA also found all medication storthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240611092503

Allegation investigated: Facility staff speak inappropriately to residents Facility staff restrain resident's in a rough manner Facility staff do not administer resident's medication as prescribed

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and residents and made observations during the course of the investigation. Complaint alleges facility staff speak inappropriately to residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Complaint alleges facility staff restrain resident's in a rough manner. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Continued onto LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240626090026

Allegation investigated: Staff hit resident Staff screams at residents

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties and made observations during the course of the investigation. Complaint alleges facility staff hit resident. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Complaint alleges staff screams at residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Continued onto LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240617155026

Allegation investigated: Staff block facility exit doors Staff does not ensure resident's hygiene needs are being met

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff, reviewed resident and staff records and made observations during the course of the investigation. Complaint alleges staff block facility exit doors. Based upon interview with multiple memory care staff, (S1, S2, S3 & S4) there is confirmation of incidents in which staff observed furnishing items being used to block the exits of residents in the memory care unit during evening shifts. Complaint alleges staff does not ensure resident's hygiene needs are being met. Based upon, facility tour, LPA Mutialu observed resident (R1) on their wheelchair in their bedroom with soiled clothing (photos taken). In addition, based upon interviews with staff (S3 & S4) it was stated that residents have been left in soiled clothing/continence products withouthe state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240610105634

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not properly trained Staff are not attending to resident care needs in a timely manner

On 6/20/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman and Resident Service Director, Grace Montemayor. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and made observations during the course of the investigation. Complaint alleges, staff are not properly trained. Upon review of resident records and information provided by staff, it was found that resident (R1) requires a two-person assist along with the use of a hoyer lift. The review of training records revealed that 12 total caregiver staff received hoyer lift training as of 6/13/2024. However, training was not implemented prior to staff providing postural support and hoyer lift services to resident R1. Continued onto LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 21-AS-20240516084802

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Neglect/Lack of Supervision resulting in resident falls with injury(ies)

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Magnolia Court for the purpose of conducting a complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility. During the investigation, LPA interviewed staff and outside parties, reviewed documents and made observations. Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). (Continued on 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 21-AS-20231204144402

Allegation investigated: Staff does not provide adequate supervision resulting in resident leaving facility.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Magnolia Court for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility. During the course of the investigation, LPA interviewed staff, residents and outside parties. LPA reviewed documents during the investigation. Complaint alleges that Staff does not provide adequate supervision resulting in resident leaving facility. Based on the interviews, LPA could not prove or disprove the allegation. LPA received inconsistent information regarding what actually transpired. LPA reviewed documents and found three Responsible Parties identified on the Emergency Contact form. During the incident in question, the resident left the facility with Responsible Party #3 who is allowed to take the resident on outings and outside of the facility. Facility was made aware that Rethe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 21-AS-20231003122141

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.