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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701306
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:40:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2024 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20240904151144
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
342701306
ADMINISTRATOR:SELLERS, ALYSSAFACILITY TYPE:
740
ADDRESS:9325 EAST STOCKTON BLVD.TELEPHONE:
(916) 877-7835
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 88DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kaushik Sharma, Business ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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On 6/20/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Business Manager Kaushik Sharma (S1) and stated the purpose of the visit. The Administrator/Executive Director Alyssa Sellers (AD) is not available during this visit.

The investigation into the above allegation consisted of document reviews of Resident (R1)’s records, including, but not limited to, Care Notes, Medication Administration Record (MAR) from 3/6/2024 to 9/6/2024, and Controlled Drug Record.




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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240904151144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/20/2025
NARRATIVE
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A review of R1’s care notes indicates that R1 started an antibiotic on 3/6/24, which was prescribed to be taken twice a day for 10 days. However, a review of R’1 Medication Administration Record (MAR) revealed that this antibiotic was given correctly in the PM dose from 3/10/24 to 3/19/24, completing the 10-day course in the PM. But in the AM, the medication was only administered for 9 days, missing one dose. R1 should have finished the dose in the morning of 3/20/24. Review of R1's Controlled Drug Records confirms one missing dose in the morning of 3/10/24.

Additionally, R1 began another antibiotic on 5/9/24, which was prescribed to be taken twice a day for 10 days. The care notes showed that this medication was properly administered both in the AM and PM, with no issues or missed doses noted.

However, another antibiotic, Nitrofurantoin (Macrobid), prescribed for 5 days, was not given as prescribed. The MAR shows that R1 only received the medication for 4 days in the AM (from 6/29/24 to 7/2/24) and 3 days in the PM, instead of the full 5-day course as directed by the prescription. Review of R1's Controlled Drug Record shows that this medication was initially given to R1 on 6/29/24 in the morning and last given on 7/2/24 in the morning.

These discrepancies indicate that staff did not administer medications exactly as prescribed. The first issue was the missing AM dose in March, and the second issue occurred when the 5-day course of Nitrofurantoin was not completed as prescribed in July. Therefore, this allegation was SUBSTANTIATED. The above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099-D during this visit. LPA discussed plan of correction with the Administrator over the phone.

Exit interview was conducted with Kaushik Sharma (in person) and Carley Taylor (via phone) to discuss the report and plan of correction. A copy of this report and appeal rights were provided.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240904151144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a)...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.
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Per discussion, the Administrator agreed to submit a letter of understanding of the cited regulation to the Department by POC due date.
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This requirement is not met as evidenced by:
Based on document review, Resident (R1) did not received their antibiotic medication as per physician's orders. This poses an immediate health, safety and personal risk to R1.
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Additionally, per Administrator, a refresher medication training will be conducted and copy of staff training will be submitted to the Department by 6/27/25.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
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