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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005529
Report Date: 12/30/2022
Date Signed: 12/30/2022 11:15:42 AM


Document Has Been Signed on 12/30/2022 11:15 AM - 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 SENIOR LIVING, THEFACILITY NUMBER:
347005529
ADMINISTRATOR:NAVDEEP KUARFACILITY TYPE:
740
ADDRESS:9325 E STOCKTON BLVDTELEPHONE:
(916) 714-3755
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 71DATE:
12/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Samantha PoleTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility. LPA met with Business Manager Samantha Pole, and explained the purpose of the visit.

A Decision and Order was served to Staff 1 (S1) on December 15th, 2022. The Decision and Order shall become effective December 27th, 2022. S1 is "prohibited from being a licensee, from employment in, presence in, and contact with clients, and from being an administrator, from holding the position of member of the board of directors, executive director, or officer of the licensee, or manager of a licensee or entity controlling a licensee, of any facility licensed by the Department, from being certified or approved by a licensed foster family agency or county, or any resource family home, and from owning a beneficial ownership interest of 10 percent or more in a licensed facility, for the reminder of [S1]'s life..."

According to records, S1 was employed from 08/01/2022 - 10/31/2022. S1 quit without notice and the staff are unsure of the person's whereabouts.

No deficiencies observed. An exit interview was held, and a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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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