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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700873
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:21:55 PM

Document Has Been Signed on 10/25/2023 12:21 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:MEADOWOOD HOME, LLCFACILITY NUMBER:
342700873
ADMINISTRATOR:ASTORGA, ANTONIETTEFACILITY TYPE:
734
ADDRESS:4701 MEADOWOOD WAYTELEPHONE:
(916) 662-5684
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 5CENSUS: 5DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Antoinette AstorgaTIME COMPLETED:
12:30 PM
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On Monday October 25, 2023, Licensing Program Analyst Kevin Mknelly arrived to conduct the unannounced annual inspection. Administrator arrived to assist.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (5) and staff files (3). All resident files contained the required paperwork. All staff files contained the required paperwork and training. One LVN and two DSP's were present to assist with care.

Facility had a full supply of PPE including face shields, surgical masks, N95s, and gowns. LPA observed the facility's emergency food and water supply. Facility was clean and well organized. Facility is current on fire drills, conducted monthly with staff. LPA reviewed the facility's generator testing logs. All required posting were observed. Facility has fire extinguishers with a current inspection. Facility has a fully stocked first aid kit.

LPA Mknelly and LVN toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas, garage and backyard. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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