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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:55:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:SAMANTHA MURPHYFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 72DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Debra Duval- Executive DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/20/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA arrived at the facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for ED to submit documents to Community Care Licensing by 10/27/2021.
  • LIC 200
  • Designation of Administrative Responsibility LIC 308
  • Liability Insurance
  • Facility Floor Plan LIC 999
  • Fire Clearance
  • Control of Property- Rental Agreement


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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