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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005529
Report Date: 09/07/2023
Date Signed: 09/07/2023 10:38:47 AM


Document Has Been Signed on 09/07/2023 10:38 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:ALYSSA SELLERSFACILITY TYPE:
740
ADDRESS:9325 E STOCKTON BLVDTELEPHONE:
(916) 714-3755
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 82DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Alyssa SellersTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met wit Administrator Alyssa Sellers, and explained the purpose of the visit.

LPA Valerio received an incident report and SOC 341 submitted by the facility on 08/02/2023. Resident 1 (R1) left the facility unassisted and walked next door to a chiropractor's office to obtain information for services. R1 fell in the parking lot while walking back to the facility and scraped R1's right arm. The staff inside the chiropractors office called Meadows Senior Living to inform them of the incident involving R1. Staff from Meadows Senior Living assisted R1 back to the community and applied basic first aid. R1 was monitored the rest of the evening and placed on alert charting. R1 declined emergency services.

According to Administrator, R1 is doing well and did not sustain additional injuries. R1's chart was updated, communication with R1's physician is on-going, and assessments are current. R1 is on the Assisted Living side, is fairly independent, and was visiting that day with R1's family member prior to leaving to the chiropractor's office. TA was provided.

Per California Code of Regulations (CCR), no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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