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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701306
Report Date: 11/12/2024
Date Signed: 11/12/2024 03:58:11 PM

Document Has Been Signed on 11/12/2024 03:58 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: 160TOTAL ENROLLED CHILDREN: 0CENSUS: 96DATE:
11/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Ashley Melendez, Director of Health and WellnessTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/12/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding an incident occurred on 10/31/24. LPA met with the facility's Director of Health and Wellness (DHW), Ashley Melendez, and stated the purpose of the visit.

Per incident, Resident (R1) attempted to take walker from another resident's space. Staff (S1) attempted redirection, then S1 and R1 got into a "scuffle" over the walker which resulted in R1 falling. R1 was taken to the hospital and was diagnosed with the following: D1, D2, D3, and D4. Further review of the incident indicated that facility investigated the incident and found that the fall was deemed to be suspicious and that local law enforcement and Local Long-Term Care Ombudsman were notified.

During an interview with DHW, it was confirmed that they reviewed the surveillance footage of the incident and determined that R1 did not hit anyone, which contradicted the information recorded in R1's Progress Notes on 10/31/24. DHW explained that R1 had taken a walker from another resident's room and walked out. S1 then took the walker from R1, leading to a "scuffle" between S1 and R1, which caused R1 to fall. Following their internal investigation, DHW reported that S1 was terminated as a result.

During this visit, LPA conducted a review of the surveillance footage of the incident on 10/31/24. LPA also conducted a review of R1's physician's report and Progress Notes dated 10/31/24 to 11/1/24.

During today's visit, LPA obtained relevant documents related to R1 and S1 for further review. LPA also obtained copy of the following facility file including a personnel report, the staff schedule for the week of 10/26/24 to 11/1/24, and staff contact information. Additionally, LPA recorded part of the surveillance footage from 10/31/24.

Based on today's visit, further investigation is needed. Exit interview was conducted with Ashley Melendez and a copy of this report was provided.
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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