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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004702
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:16:42 PM


Document Has Been Signed on 03/28/2022 04:16 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MEADOWS AT COUNTRY PLACE, THEFACILITY NUMBER:
347004702
ADMINISTRATOR:GURSHAHBAZ SINGHFACILITY TYPE:
740
ADDRESS:10 COUNTRY PLACETELEPHONE:
(916) 706-3949
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:34CENSUS: 23DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Junelle PangilinanTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 3/28/21 at 10:00am. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, medication Technician and Beatrice Diwata, Medication Technician and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 34 bedridden clients. The Administrator Certificate expires on 11/19/2022 for Junelle Pangilinan. The facility has an approved hospice waiver for 10 and there is 1 resident using hospice services at this time.

LPA interacted with a random number of residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed residents participating in group activities using social distancing during this visit. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry room, knives to be locked, required furniture, and lighting throughout the facility. LPA 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 70*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 127.8*F which is not less than 105 degrees F (40.5 degrees C) and more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed hot water temperature to be too high in the bathroom and 2 resident rooms which will be cited during this visit. 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.
Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308, Liability Insurance, Personnel Report LIC500, Qualifications of Administrator/Facility Manager-Certificate
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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 03/28/2022 04:16 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited

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Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows:Faucets used by residents for personal care...attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by: License did not ensure the water temperature was within the required range of 105-120*F
Based on LPA measured the water temperature in the bathroom, and 2 resident rooms which all read above the acceptible range of 120*F. This possess an immediate health and safety risk to residents in care.
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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