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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208851
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:07:53 PM

Document Has Been Signed on 05/31/2022 01:07 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MEADOW SPRINGSFACILITY NUMBER:
157208851
ADMINISTRATOR:HOUCK, HELENFACILITY TYPE:
740
ADDRESS:6013 FRIANT DRIVETELEPHONE:
(661) 742-1171
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Helen Houck, Licensee/AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 5/31/22 at 11:04 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Licensee/Administrator Helen Houck arrived a short time later.

LPA conducted tour with staff and did not observed any obstructions. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Administrator has current certificate. Staff records checked for good health and training on infection control. Residents all have updated emergency contact information.

The following deficiency was observed:
1. R1's bed was observed with a one side padded full length bed rail and there was no proof of a doctor’s order for a padded full length bed rail.

The following updated forms to be sent to CCL within 2 weeks: LIC500, LIC400, LIC402, LIC610E

Deficiency is being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Licensee Helen Houck, whose signature confirms receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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Document Has Been Signed on 05/31/2022 01:07 PM - It Cannot Be Edited


Created By: Malia Thao On 05/31/2022 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MEADOW SPRINGS
FACILITY NUMBER: 157208851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, interview, and record review, the licensee did not comply with the section cited above. R1's bed was observed with a one side padded full length bed rail and there was no proof of a doctor’s order for a padded full length bed rail, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee removed the padded full length bed rail bed and replaced R1's bed with one without the padded bed rail. POC cleared during the inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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