397004544-10-26-2023-27-AS-AJON-CWYNDW-20231026102259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004544
Report Date: 07/05/2023
Date Signed: 10/26/2023 10:22:59 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230330170441

FACILITY NAME:	MEADOW CREEK VILLA		FACILITY NUMBER:	397004544
ADMINISTRATOR:	MELVIN SERBAN		FACILITY TYPE:	740
ADDRESS:	4930 MOORCROFT CIRCLE		TELEPHONE:	(209) 982-4262
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	6	CENSUS: 2	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	M. Serban		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is utilizing bedrails for a resident in care.

INVESTIGATION FINDINGS:

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Allegation:Facility is utilizing bedrails for a resident in care

The facility has orders for the bedrails and the orders are dated 9/24/2020. The order is for half rails for 99 months. The ordering Doctor was Le.MaiTMD.

Based on records reviewed the facility is following the orders from the PCP.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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