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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701306
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:13:59 PM

Document Has Been Signed on 05/06/2024 03:13 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
342701306
ADMINISTRATOR/
DIRECTOR:		SELLERS, ALYSSAFACILITY TYPE:
740
ADDRESS:9325 EAST STOCKTON BLVD.TELEPHONE:
(916) 877-7835
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 160CENSUS: 90DATE:
05/06/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Alyssa SellersTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 5/6/24, at 10:46am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their post-licensing visit. LPA met with Alyssa Sellers, current Executive Director (ED), and explained the purpose of the visit. The facility currently has an approval to retain/accept 10 hospice residents and fire cleared to retain/accept 24 bedridden residents.

LPA and ED toured the facility to ensure compliance of Title 22 regulation. LPA observed the first floor, second floor, the activity room, dining room, cinema room, elevator, and random resident apartments/units. Facility has a 160-resident capacity for both assisted living and memory care residents. Currently, there are 90 residents in care, including the 17 residents living in the memory care area. Facility is a two-story building. Memory care is located on the first floor. Each floor has medication room and medications were observed to be properly stored, locked and inaccessible to residents in care. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 4 of 4 resident apartments/units were observed to be clean, sanitary and free of obstruction. Each bedroom in the memory care was observed to have an electronic monitoring system installed at the ceiling to monitor resident falls. Per interview with ED, the system detects when a resident falls and notify the care staff. Memory care has delayed egress doors.

LPA observed a shaded area in the yard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. The facility does not have bodies of water.

Water temperature in 2 randomly selected bathroom (in a resident apartment/units) were measured at between 105 and 120 degrees F. Room temperature in 4 random resident apartments/units were observed between 70 and 75 degrees F. During the visit, the facility staff conducted a fire drill and the alarms were found to be operable.

Con't to LIC809-C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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Document Has Been Signed on 05/06/2024 03:13 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 05/06/2024 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. During a review of 10 sample resident files, it was determined that 4 of 10 resident were diagnosed with dementia and 3 of them did not have updated physicians reports and reappraisals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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Administrator to ensure that all residents diagnosed with dementia to update their medical assessment and their needs and services plan annually in order to address any changes in their care needs related to dementia care.
Administrator will submit a statement of understanding of the CCR 87705 Care of Persons with Dementia and submit to the Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306
VISIT DATE: 05/06/2024
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LPA conducted file review of 10 resident files and 10 staff files. During resident file review, it was determined that 4 of the 10 residents were diagnosed with dementia. Further review indicated that of the 4 residents with dementia, 3 of which did not have updated physician report and needs and services plan. Per interview with ED confirmed that these required documents were not updated annually as per regulation for the care of persons with dementia. 10 of 10 staff files reviewed were in compliance with Title 22 regulation. LPA obtained a copy of their current resident roster, staff roster and staff schedule.

The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted with Alyssa Sellers, ED, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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