Magnolia Care Home 1

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Melina Oropeza arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and back up administrator, Muanoudou Sounahoro joined 40 minutes later. LPA explained the purpose of the visit to back up Administrator and staff. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals were noted to be locked to residents in care. LPA also conducted the care tool. Hot water temperature was measured at 107 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers inspected on 06/30/26 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed two (2) staff files. All staff is fingerprint cleared and associated to the facility. 1 out of 2 staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed three (3) resident facility files and survey binder. All necessary documents were in place. During today's visit, LPA observed a cockroach infestation in the kitchen, dining area, cabinets and food preparation areas, centrally stored medications were left unlocked and accessible to residents, pre-poured medications were left unattended, 5 out of 5 residents evening medications had been initialed on the MARS prior to being administered to residents, cobwebs throughout the facility and a damaged front screen door with a hole in the screen. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Administrator to email and text copies of corrected deficiencies to LPA Oropeza at Melina.Oropeza@dss.ca.gov. Exit Interview was conducted. Appeal Rights were printed and a copy of report was given to the back up administrator, Muanoudou Sounahoro.the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behaviors

Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unanounced to deliver findings of a complaint with the above allegation, LPA met with staff gertrude mwaashidzana and administrator Miriam by phone. The allegation was investigated by record review, interview, and observation. The facility has a resident with wandering and dementia, the record review of the staff schedule detailing the noc shifts 2-hour checks on the resident was not filled out on two seperate occasions the LPA came by to review it. In interviews two of the 3 staff are saying there was an incident caused by this resident wandering into other clients rooms at night. LPA observed the resident wander around the facility, without redirection from the staff to avoid entering the room of the client who does not want to share that private space. Based on LPAs observations and interviews 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 is being cited on the attached LIC 9099D. Appeal rights and a copy of the report were read and provided to the staff. Exit interview was conducted. Substantiated The opening of the mail was done in the context of the regular duties of the staff to assist in the clients medication needs, packages from the pharmacy were opened, regular mail was not. LPA observed resident did have the admission agreement in thier possession, facility and family member present at the time of the signing report it was given to the resident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Appeal rights and a copy of the report were read and provided to the staff. Exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250624162907

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 4, 2025

87468.1 personal rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: record review of staff duty list not documenting wandering resident is checked at night. 2 staff interviews indicating that an inccident occured where wandering resident entered the room of another resident at night, this consitiutes a personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: nightly Logs from awake staff showing observations from the supervision at night, at minimum 2 hour checks to know if the residents are agitated and in need of intervention, should be sent to the LPA end of day tomorrow, 9/4/25 and then again at the end of the month 9/30/25. the practice should continue as long as dementia residents with wandering behavior are in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unanounced to follow up with a Plan of Correction given to the Licensee, LPA met with staff gertrude mwaashidzana and administrator Miriam by phone and explained the purpose of the visit.. Physical inspection of the facility was conducted. The LPA observed Chemicals were put away into lockable storage. No chemicals where observed in reach of the wandering dementia resident. 2 staff interviews were conducted. Staff were able to relay specific information about dementia client care to the LPA in accordance with thier recent training. Documentaion reflecting updated cpr/first aid certification is present. Licensee is compliant with the plan of correction at this time. A copy of the report was read and given to staff. and exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct an annual visit on 7/25/2025 at 12:00pm, The LPA asked the staff gertrude to call the administrator so the purpose of the visit could be explained. Magnolia care home 1 is a 6 bed facility for the elderly with 5 residents in the current census. 2 ambulatory, 3 nonambulatory. 1 has dementia. 2 are on hospice. 4 have diabedes(controlled via PO medication). Physical Plant was inspected, including but not limited to the kitchen, common areas, client bedrooms, client bathrooms, exteriors, and evacuation routes. The facility is clean, and traffic areas are well lit and unobstructed. the kitchen has adequate lockable storage for sharps and toxics, there is 2 days of perishible/7 days of nonperishable foods. MARs for each of the residents were checked; in 1 of 5 records a psychotropic medication(trazadone) was not documented as given when it was for many days this month. The common areas are clean and have enough space for activities. the bathrooms have hardware in good repair, temperature was measured at 118*F. LPA observed hygine related toxics(hand soaps/shampoos/conditioners/hairsprays) within access to ambulatory dementia client. Client is on 1 to 1 supervison, it is unlikely she would use the bathroom by herself, however she does wander at night. The Licensee is going to store the offensive chemicals locked. The exterior screens are in good repair, plenty of space for activies, no tripping hazards. evacuation route gate is in good repair. Fire extinguisher was last checked 5/19/25. Posters in cluding the facility sketch, administrator cirtificate, facility license, federal work requirements, personal rights, and the ombudsman information are all present and of the correct dimension. Continued on C Page. 5 of 5 Client records were reviewed, the files included but were not limited to the signed admission agreements, physicicians reports, hospice care plans, preadmission apprasials, and emergency contact information. Files were found to be present and up to date. Personal property for 1 of the clients was labled "cloths" with no itemization, personal property for 1 of the clients was missing signtures and numbers regarding some expensive property(television, cellphone, ect). Licensee is going to get the Personal property reinventoried and get signatures from the clients or thier representatives. 3 of 3 Staff records were reviewed, including but not limited to criminal background checks, fingerprinting, cprt/first aid training, and annual continuing trainings. 2 staff do not have an up to date cpr/first aid training on file, 3 staff do not have continuing training with regard to the specific topics within dementia care or the general topics in RCFE care. There is staff on duty with a up to date cpr/first aid at the time of this report. Licensee reports at least 1 staff having an up to date cpr/first aid training that has not yet been added to the file. Licensee provided the training would be completed as soon as possible and continued annually into the future. Administrator records were reviewed, including but not limited to the program design, sample admission agreement, liability insurance, evacuation plan, administrator certificate, facility license, shift logs, staff roster, and client roster. Documents are present and up to date. Client interviews, 2 clients were interviewed. concerns related to the high salt content of the meals were raised. Staff interviews, 2 staff were interviewed. staff are unfamilar with resident rights and abuse reporting requirements. Per title 22, Citations, Technical Violations, and Technical Advisories were given as a result of this visit. LPA is requesting a updated 610E, sent to the LPA(noel.wolfpetersen@dss.ca.gov) by 8/1/25 An exit interview was conducted, the copy of the report was read and given to the staff.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Case Management - Other

*****This report is being amended to confirm that on 4/24/2025, LPA identified the wrong facility on a case management visit and a report was printed. This facility was the facility in question and as a result was identified as closing. However, this is not the case. This facility is currently in compliance and has not given or been notified of any closure proceedings by the department or the licensee as written on the report dated 4/24/2025.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection. LPA met with direct care staff and explained the purpose of the visit. Administrator certificate expires on 8/22/2024. LPA and direct care staff toured the physical plant including but not limited to resident bedrooms, resident bathrooms, dining room, patio, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.8 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers; smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 8/25/2023. Emergency Disaster Drill conducted on 5/2/2024. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents. LPA reviewed four resident files and two staff files, including criminal record clearances. A review of staff records indicates that all staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents for community care licensing to be submitted via email by June 7, 2024: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance with expiration date. ruth.wallace@dss.ca.gov Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today. Exit interview conducted with direct care staff. A copy of report and LIC 811 (Confidential Names) left at facility.the state’s words, verbatim · CDSS document, Jun 4, 2024