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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:35:24 PM

Document Has Been Signed on 02/13/2025 02:35 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/
DIRECTOR:		JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 108TOTAL ENROLLED CHILDREN: 0CENSUS: 70DATE:
02/13/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jessica SanderTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On February 13, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator .

The visit conducted today is to review the amended report created in 1/14/25.
On 1/14/25 an incorrect regulation was cited for the CCR 87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures.

As the deficiency did occur but was incorrectly cited, the deficiency was removed from the 1/14/25 report and is being re-issued at this time.

The plan of correction for the deficiency has been completed. No further action is required by the licensee at this time.

While present LPA reviewed a medication error that occurred on 1/31/25. A plan of correction had already begun. The resident was uneffected by the error and supervisory action has been initiated for the staff.

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


Report reviewed. Copy of report and appeal rights provided
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925
DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/13/2025 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROSEVILLE
FACILITY NUMBER: 317005900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87469(c)(3)

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Advanced Directives and Requests Regarding Resuscitative Measures (c)(3)(c) (3) Specifically for a terminally ill For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
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This deficency was originally cited on 1/14/25.
This deficiency is being delivered with an amended LIC809 D for 1/14/25.

This deficency's POC has been cleared.
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This requirement was not met met based on records review and statements that found resident with an unwitessed fall did not receive emergency response. This posed an immediate risk to the resident.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025

LIC809 (FAS) - (06/04)
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