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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:47:25 PM


Document Has Been Signed on 07/20/2023 01:47 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MEADOWVIEW MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:N/AFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 16DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Beatrice BurkettTIME COMPLETED:
02:00 PM
NARRATIVE
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On 07/20/2023, an unannounced case management visit was conducted by Licensing Program Analysts (LPAs) Kimberly Viarella and Kevin Gould to this facility. LPAs identified themselves and explained the purpose for their visit and asked to speak with the designated facility administrator. They were met by Caretaker/Designee, Beatrice Burkett. LPAs instructed the Designee to inform the Licensee of their arrival to the facility. A brief interview followed.

During a complaint visit on 06/22/2023, LPAs inspected all medication logs. LPAs noted that when a PRN medication was given, it was written in a notebook, however the reason for providing the medication and its effectiveness were not documented. This posed a potential health and safety risk to residents in care. LPAs reviewed the proper documentation procedures. LPAs also reviewed medication lists for residents, however they were not updated. LPAs observed new medication orders were taped on the refrigerator, which was also a violation of the residents’ right to confidentiality.

On 06/22/2023 when LPA Kimberly Viarella arrived to conduct a complaint investigation, there was no qualified Designated Facility Administrator present, as of today’s date there is no Administrator of record. According to the Non-Compliance Conference that was held on 05/16/2023, the Licensee was instructed to have a Designated Facility Administrator on the premises 40 hours a week.

During today's visit, LPAs noted that two employees had not received their background clearances. Civil Penalties were issued.

During the visit conducted on 06/22/23, the staff member that met with Licensing that day was also unable to produce an LIC 500 upon request. LPA left selected copies of the Medication Guidelines to assist licensee with compliance.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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 5


Document Has Been Signed on 07/20/2023 01:47 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2023
Section Cited
CCR
87465(b)(3)

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Incidental Medical and Dental Care
(b)If the resident's physician has stated...for a prescription...(3) A record of each dose is maintained in the resident's record. The record shall include ... the PRN medication was taken, the dosage taken, and resident's response.
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Licensee agrees to arrange training for staff through contracted agency by by 08/20/2023. The name of the agency, the trainer, the date of the training, and a sign-off sheet for all employees who participated in the training will be sent to Kimberly.viarella@dss.ca.gov.
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Based on records review and interviews LPAs observed incomplete medication logs. Reasons for PRNs and the outcome of their effectiveness were not documented for any of the residents in care. This posed a potential health and safety risk to residents 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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2023 01:47 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.,. The administrator shall have... freedom from other responsibilities and shall be on the premises a require that the administrator devote... to fulfill responsibilities...
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Licensee will hire a Certified Administrator.
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This regulation was not met as evidenced by:
Based on observation and interview, the facility failed to provide a certified administrator. This posed an immediate health and safety risk to residents in care.

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Type B
07/27/2023
Section Cited
CCR87421(f)

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Personnel Records - All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This regulation was not met as evidenced by:
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Licensee will store the personnel records in a location that is accessible to licensing so they will be available upon request. The LIC 500 will be stored in the medication cabinet. (This was done immediately to clear the POC.)
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Based on observation and interview, during the visit conducted on 06/22/23, the staff member that met with Licensing that day was also unable to produce an LIC 500 upon request. This posed a potential threat to the health and safety of residents 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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
VISIT DATE: 07/20/2023
NARRATIVE
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The following deficiencies were observed and cited according to the California Code of Regulations (Title 22, Division 6) on the following LIC 809 D page.

Licensee, Bea Schoon called and gave permission over the phone for this LPA to meet with Beatrice Burkett to review/sign all reports today and to develop plans of correction.

A copy of this report and Appeal Rights were provided to Beatrice Burkett at this time.

Exit Interview.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/20/2023 01:47 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This regulation was not met as evidenced by:
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The individual who was not cleared will go to get fingerprinted within 24 hours and submit a screen shot of the receipt to kimberly.viarella@dss.ca.gov.
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Based on record review, observation and interview, 1 employee had not completed the backgroud check process prior to employment.
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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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5