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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005529
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:45:32 AM


Document Has Been Signed on 12/02/2022 10:45 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: 79DATE:
12/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ayssa SellersTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit due to received multiple incident reports and an eviction notice for resident 1. LPA met with Executive Director Alyssa Seller and explained the purpose of the visit.

LPA discussed the incident reports, SOC 341, and eviction noticed with ED. Any time resident had an incident, the facility had it documented in the chart. According to records and interviews, resident 1 had incidents with staff. Before the eviction notice was given, the resident informed the facility R1 would be out by 12/01/22. R1 had moved out on 11/30/22. LPA interviewed staff and a resident during the visit.

Per California Code of Regulations, Title 22, no deficiencies were observed during the visit. An exit interview was held, and a copy of the report was left.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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