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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700183
Report Date: 11/17/2023
Date Signed: 11/17/2023 10:41:12 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/17/2023 10:41 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MEADOW VISTA HOME AT DURELLOFACILITY NUMBER:
342700183
ADMINISTRATOR:ASTRONOMO, MARIA SHENICA RFACILITY TYPE:
735
ADDRESS:3420 DURELLO CIRCLETELEPHONE:
(916) 895-1470
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ma Rosario ReyesTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/17/23 at 9:30AM to conduct a Required - 1 year inspection visit. LPA met with Ma Rosario Reyes, Caregiver and explained the purpose of the visit. Caregiver Ma Rosario Reyes contacted the Administrator regarding todays visit. LPA observed the facility has an Infection Control Plan on file.

The facility is licensed for a capacity of 4 non-ambulatory residents. LPA observed 3 residents and 1 is out in the community during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The last documented emergency drill was conducted on 10/17/23.

The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.9*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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