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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 10/26/2023
Date Signed: 10/27/2023 08:28:31 AM


Document Has Been Signed on 10/27/2023 08:28 AM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 91DATE:
10/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Executive Director: Nathan CondieTIME COMPLETED:
04:15 PM
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On 10/26/2023, 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 09/25/2023. LPA met with Executive Director, Nathan Condie, and explained the purpose of the visit.

The Case Management visit is in response to an incident report that was submitted to CCLD. Incident report indicates, a bubble pack of 30 Tramadol 50mg was not in the Narcotic Drawer on 09/10/2023. Resident Care Director, Kathryn Nevin, was immediately notified and searched the entire medication room. The facility conducted an internal investigation. Roseville Police Department were notified via telephone. Case number was provided. R1's doctor notified for refill of medication. R1's responsible party was notified. The facility provided in-service on 9/23/2023 and 9/24/2023 in regards to policy on narcotic count and general medication room policies and procedures.

LPA requested for in-service training for review.

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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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