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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004544
Report Date: 09/12/2024
Date Signed: 09/13/2024 09:25:07 AM


Document Has Been Signed on 09/13/2024 09:25 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 1DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Administrator Melvin SerbanTIME COMPLETED:
06:45 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with the Administrator Melvin Serban and explained the purpose of the visit. Census:1

LPA Lund & Administrator Melvin Serban toured/inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Hot water temperature was measured at 114 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers (5/31/2024) and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. Fire drill was conducted on 7/10/2024. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed one resident and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

No deficiencies cited during the visit and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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