557000412-7-20-2023-27-AS-KHOS-CU5QJ5-20230727121211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:48:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
05/26/2023 and conducted by Evaluator Kimberly Viarella

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230526114803

FACILITY NAME:	MEADOWVIEW MANOR		FACILITY NUMBER:	557000412
ADMINISTRATOR:	SHERIL DUPUICH		FACILITY TYPE:	740
ADDRESS:	19227 SOUTH COURT		TELEPHONE:	(209) 533-0935
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	20	CENSUS: 16	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Beatrice Burkett, Caretaker/Designee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff mismanaged residents medications
Facility staff are not disposing of medication timely

INVESTIGATION FINDINGS:

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On 07/20/2023, an unannounced complaint visit was conducted by Licensing Program Analysts (LPAs) Kimberly Viarella and Kevin Gould to this facility to deliver the results of an investigation. LPAs identified themselves and explained the reason for their visit and asked to speak with the designated facility administrator. There is no Designated Facility Administrator at this time. They were met by Beatrice Burkett, Caretaker/Designee. A brief interview followed. The Licensee Bea Schoon was contacted by staff and gave permission for Beatrice Schoon to be her designee and meet with LPAs.

On 6/22/2023 Community Care Licensing (CCL) representatives performed a case management visit to this facility and observed medication pre-poured 2-3 weeks in advance. Through interviews, records review, and observation, LPAs learned that no log or record is transcribed when a resident was given a routine medication. 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. LPAs observed medication lists

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230526114803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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for residents, however they were not updated. New medication orders were taped on the refrigerator. LPAs requested to inspect the destruction log and none could be provided.

The following deficiencies were observed and cited according to the California Code of Regulations (Title 22, Division 6) on the following LIC 9099-D.

Appeal rights were provided and a copy was given to the Designee, Beatrice Burkett at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230526114803

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 07/27/2023 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.	1 2 3 4 5 6 7	Licensee will submit a letter of understanding stating that they will no longer pre-pour medications for more than 24 hours. Licensee will provide medication training to employees through a contracted agency. The name of the agency, trainer and date of training will be submitted to:
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the observation LPAs observed residents’ medications pre-poured into different containers for 2-3 weeks. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	submitted to kimberly.viarella@dss.ca.gov by 07/27/2023.
Type B 08/10/2023 Section Cited CCR 87465(i)(4)	1 2 3 4 5 6 7	(i) Prescription medications..., not returned to the issuing pharmacy, nor re-tained in the facility as ordered... disposed of according to the hospice’s established procedures or which are ... to be disposed of shall be destroyed in the one other adult who is not a resident. Both shall sign a record ...for at least three years, which lists the following: (4) The date of destruction.	1 2 3 4 5 6 7	Licensee will train all staff of medication disposal procedures. A signature sheet as proof of attendance will be submitted to kimberly.viarella@dss.ca.gov by 08/10/2023
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: The facility did not have a destruction log.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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