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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005529
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:59:21 PM

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: DATE:
08/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Nurse Director Nisha KuarTIME COMPLETED:
05:15 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
On 08/17/2021 at 4:15 PM, Licensing Program Analyst (LPA) Christina Valerio arrived unannounced at the facility to conduct a case management visit. The Department received notification of their sister facility, Eagle Lake Village, evacuating residents to The Meadow Senior Living due to a fire in Susanville, Zip code 96130

LPA Valerio inspected the physical plant. LPA did not observe any health and safety concerns. The facility has enough food supplies, paper supplies, and hygiene supplies. Facility has placed an order for all materials,which should arrive in a couple days.

LPA Valerio observed the facility receiving resident medical information and profile from facility Eagle Lake Village through their online database, Eldermark.

LPA observed the staff schedule. There will be 3 caregivers and 1 medication technician on shift this evening for memory care. For the assisted living side, there will be 3 caregiver and 2 medication technicians. Nurse Director Nisha and Executive Director Jacob Primeau will be working split shifts (Evening and NOC) to ensure a smooth transition.

Maintenance staff is picking up 20 cots and blankets from outside agencies and Sacramento County. Walmart and Target have donated supplies to the facility as well.

Exit interview held with Nurse Director Nisha. LPA Valerio left contact information.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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 1