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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004544
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:14:17 PM


Document Has Been Signed on 07/12/2023 12:14 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: 3DATE:
07/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Daniell SerbanTIME COMPLETED:
11:46 AM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management Visit. LPA met with Daniell Serban.

LPA confirmed that the plan of correction was completed and the facility has met the terms of the plan of correction. The facility was given the correct address for submitting their appeal for the citation given on 7/5/23.

The facility discussed the plan for their appeal.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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