557000412-7-20-2023-27-AS-LKIG-CUPQR2-20230814122313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:08:31 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
06/14/2023 and conducted by Evaluator Kimberly Viarella

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230614133729

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:	10:45 AM
MET WITH:	Beatrice Burkett, Caretaker/Designee		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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An excluded individual was present in the facility
Expired foods being stored in garage

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. They were met by Beatrice Burkett, Caretaker/Designee. A brief interview followed.
Allegation: An excluded individual was present in the facility.
On 06/01/1023, Community Care Licensing (CCL) served a letter of exclusion to an employee of Meadowview Manor. CCL also provided the licensee with a copy of the letter and corresponding report. The excluded individual was aware that they were no longer permitted inside the facility, but they were seen inside the facility. Based on observations and interviews, the preponderance of the evidence standard had been met, therefore the above allegation was found to be SUBSTANTIATED.
Allegation: Expired foods were being stored in garage
During a case management visit on 06/22/2023, LPAs confirmed by inspection that there were expired
(continued LIC 9099C)

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-20230614133729

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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foods being stored in the garage. LPA selected 5 random cans: 2 of the 5 were expired and dated 06/08/2023 and 11/03/2022. LPA also observed 2 of 3 large cans were dented. Items were removed at time of visit. Due to time constraint a citation was not issued on the date of the case management.

Based on observation and interviews the preponderance of the evidence standard had been met, therefore the above allegation was found to be SUBSTANTIATED.

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

Civil penalties were issued in the amount of $500 per the LIC 421 IM
Appeal rights were provided and a copy of this report was given to the 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-20230614133729

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 A 07/21/2023 Section Cited HSC 1596.99(c)(7)	1 2 3 4 5 6 7	Levy of civil penalty in addition to...appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) ... violation continues after citation, for any of the following serious violations. (7) The presence of a person subject to a department Order of Exclusion on the premises.	1 2 3 4 5 6 7	The Licensee will write a letter of understanding stating that the excluded individual will not be allowed access to the facility. The letter will be submitted to kimberly.viarella@dss.ca.gov by 07/21/2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the observation, an excluded individual was seen in the facility. The Licensee did not ensure that the excluded individual would not be permitted on the premises. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 07/21/2023 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	General Food Service Requirements (b)The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved... authorities. Food in damaged containers shall not be accepted, used or retained.	1 2 3 4 5 6 7	Licensee will schedule a monthly pantry and refrigerator/freezer check to prevent an accumulation of expired or damaged foods. This schedule will be submitted to kimberly.viarella@dss.ca.gov by 07/21/2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: This regulation was not met as evidenced by: Based on interview and observation, the LPA observed 2 out of 5 canned goods were expired and 2 out of 3 large canned goods were dented. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The expired foods and damaged containers were disposed of immediately.

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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