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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:56:47 PM


Document Has Been Signed on 02/21/2024 01:56 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 82DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Executive Director: Jessica SandersTIME COMPLETED:
02:30 PM
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On 02/21/2024, 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 02/13/2024. LPA met with Executive Director (ED), Jessica Sanders, 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, the facility were advised on 02/13/2024 from the pharmacy that a bubble pack of 30 oxycodone was delivered to the community on 02/07/2024. It was discovered that staff (S1) on the night shift signed off on the medication.

The facility conducted an internal investigation of missing bubble pack. The facility notified Roseville Police Department. Resident's primary care physician was notified and responsible party. The facility conducted an in-service on receiving, logging, and storing narcotics on 02/17/2024 and 02/18/2024. LPA requested for in-service training for review.

At this time, deficiencies are not being cited.



An exit interview conducted with Memory Care Director, Jami Koopman, and report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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