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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 01/28/2021
Date Signed: 04/02/2021 04:04:03 PM

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:MEADOWVIEW MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:SHERIL DUPUICHFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 13DATE:
01/28/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Sheril DupuichTIME COMPLETED:
05:00 PM
NARRATIVE
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On 1/28/21 Licensing Program Analyst (LPA) Kevin Gould conducted a tele-visit with Administrator Sheril Dupuich to discuss ongoing concerns with response testing for residents for COVID 19 and surveillance testing for staff as facility has both positive residents and staff and have not conducted response testing for all residents despite some residents testing positive beginning 1/19/21.

LPA Gould and Administrator discussed ongoing concerns reporting positive COVID cases to Community care licensing in a timely manner and testing remaining residents and staff who have not been tested for COVID 19. Administrator states she did not have enough time to report positive residents to licensing due to being short staffed. As of todays report, 5 residents have not been tested for COVID 19, no surveillance testing is being conducted for staff and facility could not provide documentation of schedules or appointments for remaining residents' testing.

LPA Gould inquired as to what barriers facility has in testing the remaining residents. Administrator stated they are in a rural area and have not been able to have testing conducting in the facility for residents without symptoms and are no qualified staff to administer PCR COVID testing in the facility. Administrator stated they could not get staff tested in the county if they do not show symptoms. LPA confirmed the testing requirements for staff with the county and was informed there are no restrictions to obtaining a test for COVID 19 and two testing locations within a few miles of the facility.

Based on the information obtained during interview with Administrator, the following deficiencies are cited. See LIC 809-D.

A copy of this report and appeal rights have been mailed to the facility for signature.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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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: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2021
Section Cited

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Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by: Not complying with the local health department
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and CCL requirements for response testing for residents in COVID positive facilities in a timely manner and not conducting surveillance testing of staff members which poses an immediate health and safety risk for residents in care.
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Type B
02/03/2021
Section Cited

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Reporting Requirements: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing
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 agency and to the local health officer when appropriate. This requirement was not met as evidenced by facility not reporting positive COVID residents to licensing in a timely manner, first positive 1/19/21 and licensing not informed until 1/27/21 by LPH which poses a potential risk to residents.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2021
LIC809 (FAS) - (06/04)
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