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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004544
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:27:23 PM


Document Has Been Signed on 04/14/2022 01:27 PM - 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: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:
04/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Licensee/Administrator Melvin Serban and wife Daniell Serban.TIME COMPLETED:
11:15 AM
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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 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.

Exit Interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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