347004702-4-27-2023-27-AS-VBRN-CRAQJ5-20230427121210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004702
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:12:24 PM

Document Has Been Signed on 04/27/2023 12:12 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, THE		FACILITY NUMBER:	347004702
ADMINISTRATOR:	RANGI GINER		FACILITY TYPE:	740
ADDRESS:	10 COUNTRY PLACE		TELEPHONE:	(916) 706-3949
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	34	CENSUS: 29	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Junelle Pangilinan		TIME COMPLETED:	12:15 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 to conduct a Required – 1 Year inspection on 4/27/23 at 9:00am. LPA met with Junelle Pangilinan, 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 11/19/2024 for Junelle Pangilinan. The facility has an approved hospice waiver for 10 and there is 2 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 70F 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 112.9F 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 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 reviewed records and interviewed 3 staff and 3 resident during this visit. 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, no deficiencies are being cited. An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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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