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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 10/26/2020
Date Signed: 10/26/2020 01:06:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:JASMINE RIDENOURFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 72DATE:
10/26/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Samantha MurphyTIME COMPLETED:
01:07 PM
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On October 26, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Executive Director, Samantha Murphy, via telephone to conduct an unannounced Case Management visit. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 10/11/2020. The report indicates that a resident (R1) had complaints of chest pain and was sent to the ER for a medical evaluation. R1 returned to the community the same day. R1's responsible party had been notified.

LPA interviewed Samantha regarding the report. The interview with Samantha indicates that R1 is doing well. The facility had set up an alert charting for R1 for 48 hours. LPA requested for R1's physician report, needs and services plan, and discharge medical documents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Executive Director was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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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