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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004544
Report Date: 07/05/2023
Date Signed: 07/05/2023 09:35:51 PM


Document Has Been Signed on 07/05/2023 09:35 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: 2DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:M SerbanTIME COMPLETED:
02:45 PM
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During the investigation for multiple allegation it was discovered that the facility was deficient in allowing R1 to comeback after a brief ER visit with a stage three pressure injury.

This was a healing wound, that was being addressed by home health, however, it was staged at a three and is a "Prohibited Health Condition".

The following deficiency was confirmed and cited from the California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Appeal rights were provided.

Exit interview was conducted

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/05/2023 09:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 397004544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/06/2023
Section Cited
CCR
87615(a)(1)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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The licensee shall train all staff on prohibited health conditions and submit a signed attendance roster of all employees that were educated on the regulation along with a statement of understanding to LPA by POC due date of 7/6/2023.
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This requirement is not met as evidenced by: Based on records reviewed and interviews conducted the care home retained a resident with a stage 3 pressure injury without obtaining an exception from CCL. This posed an immediate risk to the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2