347004702-5-13-2021-27-AS-VBRN-C2YTLV-20210513145010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004702
Report Date: 05/13/2021
Date Signed: 05/13/2021 02:50:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	MEADOWS AT COUNTRY PLACE, THE		FACILITY NUMBER:	347004702
ADMINISTRATOR:	LIZA SEGUBAN		FACILITY TYPE:	740
ADDRESS:	10 COUNTRY PLACE		TELEPHONE:	(916) 706-3949
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	34	CENSUS: 16	DATE:	05/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Liza Seguban		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms, not associated with a pre-existing condition? · Fever or chills · Cough · Shortness of breath/difficulty breathing · Fatigue · Muscle or body aches · Headaches · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWS AT COUNTRY PLACE, THE	FACILITY NUMBER: 347004702
	VISIT DATE: 05/13/2021

NARRATIVE

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Licensing Program Analyst(s) (LPA) Victoria Brown and Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/13/21 at 12:30pm. LPAs met with Liza Segunban, Administrator and stated the purpose of today’s visit. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 34 bedridden clients. The Administrator Certificate expires on 6/30/22. There are no residents using hospice services at this time.

LPAs interacted with a random number of residents during this visit.
The team toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The team observed residents participating in group activities using social distancing during this visit. The team observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry room. The team observed knives to be locked. The team observed required furniture, and lighting throughout the facility. LPA's observed large storage containers outside holding personal care products and decorations to be locked. The temperature inside the facility was measured on the wall thermostat at 75*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.
The hot water was measured at 113.4*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients.
The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.
LPA observed the facility Emergency and Disaster drills are conducted quarterly.
LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWS AT COUNTRY PLACE, THE	FACILITY NUMBER: 347004702
	VISIT DATE: 05/13/2021

NARRATIVE

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Upon a file review the following items were discussed to be submitted with any changes annually:

Application to be updated without fees LIC200
Designation of Administrative Responsibility LIC308
Administrative Organization LIC309
Personnel Report LIC500
Health Screening Report-Facility Personnel LIC503
Emergency Disaster Plan LIC610E to include Carbon Monoxide Detector
Qualifications of Administrator/Facility Manager-Certificate

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC809 (FAS) - (06/04)

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