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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:34:45 PM


Document Has Been Signed on 05/16/2024 04:34 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: DATE:
05/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jessica SandersTIME COMPLETED:
04:45 PM
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On 5/16/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Jessica Sanders.

LPA was following up on an incident involving R1 that occurred on 5/2/24.

LPA conducted six (6) interviews of caregivers and med techs.

LPA requested that licensee submit the following records regarding R1: Med tech notes regarding Hospice contact, Hospice care notes, Medication records, caregiver assignments document, R1's hospice care plan and prior records of a fall/ hospitalization and rehab for R1 shortly before initiation of Hospice services. Documents are requested by 5/23/24.

As a result of today’s inspection, no deficiencies were noted.

Report reviewed. Copy of report and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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