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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:55:55 PM


Document Has Been Signed on 05/04/2023 02:55 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:NATHAN CONDIEFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 88DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Assistant Executive Director: Allison LopezTIME COMPLETED:
03:30 PM
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On 05/04/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 04/25/2023. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit.

The Case Management visit is in response to an incident report and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) that was submitted to CCLD. Incident report indicates, resident (R1) made a report to the General Program Director (GPD) that a staff (S1) was cussing and speaking rudely towards R1 and R2. GPD received a written and signed statement from R1. S1 was suspended and there is a pending investigation.

LPA Keosavang requested for R1 and R2’s physician’s report, assessments, internal investigation report, and R1's written statement for review. LPA conducted interviews with facility staff.



At this time, deficiencies are not being cited.

An exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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