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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004544
Report Date: 03/09/2021
Date Signed: 05/12/2021 08:33:37 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:MEADOW CREEK VILLAFACILITY NUMBER:
397004544
ADMINISTRATOR:MELVIN SERBANFACILITY TYPE:
740
ADDRESS:4930 MOORCROFT CIRCLETELEPHONE:
(209) 982-4262
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: DATE:
03/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Melvin Serban and wife DaniellTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management Visit. LPA met with Licensee/Administrator Melvin Serban and wife Daniell Serban.

Facility was inspected both indoors and outdoors. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. There is a cabinet for personnel and client records. The emergency exiting plan, Resident rights, and licensing complaint poster is posted. Facility has a first aid kit and centrally stored locked medication. The facility has adequate lighting throughout. All bedrooms inspected have appropriate furnishings, chair, adequate lighting and storage.

Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Kitchen is clean sanitary, and in good repair. The kitchen has operable appliances. There is a locked area for cleaning supplies and toxins. The 7 day non-perishable food requirement is met.

LPA provided technical assistance for residents files and potential personal rights concerns. LPA will provide advisories for these concerns.

Exit Interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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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