<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004702
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:07:51 PM


Document Has Been Signed on 03/28/2022 04:07 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Junelle PangilinanTIME COMPLETED:
04:00 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
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent visit on 3/28/22 at 10am. This visit is to conclude the investigation of the above mentioned allegations. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, Medication Technician and Beatrice Diwata, Medication Technician and stated the purpose of today’s visit.

During the investigation of the complaint 27-AS-20220120163656 regarding an allegation of "Illegal eviction" LPA observed that on the Incident report submitted to Community Care Licensing (CCL) on 1/17/22, Administrator Gurshahbaz Singh wrote that due to covid diagnosis and frequent visits to public places not wearing a mask during covid-19, resident was taken home by family to quarantine. The Administrator stated the same information to R1's doctor and family.

The investigation revealed that the administrator wrote the SIR submitted to CCL as if R1 went with family on their own accord.

This is deemed as a false statement to the Department that will be cited.


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)
Page: 1 of 2


Document Has Been Signed on 03/28/2022 04:07 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

1
2
3
4
5
6
7
False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Administrator/License provided an SIR with misleading information to CCL. Based on previous Administrator confirming resident was not allowed to return to facility and was reluctant to state he was denied reentry to the facility. This possess an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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)
Page: 2 of 2