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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 07/27/2023
Date Signed: 07/28/2023 08:21:19 AM


Document Has Been Signed on 07/28/2023 08:21 AM - 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:
07/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bea Schoon TIME COMPLETED:
02:00 PM
NARRATIVE
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On 07/27/2023, an unannounced case management visit to this facility was conducted by Licensing Program Analysts (LPAs) Kimberly Viarella and Kesha Lewis. LPAs identified themselves and explained that the purpose to the Licensee, Bea Schoon. A brief interview followed.

LPAs requested the LIC 500 and a Resident Roster. LPAs checked to verify all employees had the required cleared background checks. At the time, the Licensee and 1 other employee were working, both had the appropriate clearances and were in compliance.

These records were easily accessible to LPAs as they were stored in the medication cabinet. This deficiency was cleared.

The Licensee offered the new Centrally Stored Medication and Destruction Log for LPAs to review. The LPA cleared this deficiency as well.

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

A copy of this report along with the Appeal Rights were provided to the Licensee.

Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 07/28/2023 08:21 AM - 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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
87405(a)

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(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...
This regulation was not met as evidenced by:
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A current employee at the facility will be registering for the Administrator Certification Program and anticipates completion by the close of business on 08/11/2023.
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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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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: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2