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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005529
Report Date: 07/20/2021
Date Signed: 07/20/2021 11:08:01 AM

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:BARBARA FLECKFACILITY TYPE:
740
ADDRESS:9325 E STOCKTON BLVDTELEPHONE:
(916) 714-3755
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 67DATE:
07/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Navdeep KuarTIME COMPLETED:
11:15 AM
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On 07/20/21 at 9:45 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to conduct an unannounced case management visit to follow up on an incident that occurred on 07/07/2021 with alleged staff and resident 1 (R1). LPA Valerio met with Health and Wellness Director Navdeep Kuar. LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to entering the facility.

Director Navdeep stated since the incident they have had staff assist R1 in pairs. The facility conducted their own investigation with interviews with staff and resident. The facility concluded that the allegation to be unfounded based on their interviews and investigation.

LPA conducted a case management inspection to ensure there are no health and safety concerns regarding the physical plant of the facility. LPA observed the facility to be clean and clear from obstructions. LPA Valerio reviewed facility nursing notes, interviewed resident, and interviewed staff on shift. LPA Valerio observed R1 to not have bruising on his hands. R1 did have a skin tear on his left arm, which has been treated by medical staff since 07/12/21.

Based on the interviews, inspection conducted and additional documentation received, the department has closed this case management and no further investigation is required.

Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was left at the facility and given to Health and Wellness Director Navdeep Kuar.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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