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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:59:00 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230918133223
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: 15DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Bea SchoonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility foods are not properly stored
INVESTIGATION FINDINGS:
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On 10/5/23 at approximately 11:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Bea Schoon and staff Beatrice Burkett and explained the purpose of today's visit.

LPA Jensen checked the refrigerator, freezer and pantry on this date and on a prior visit on 9/27/23. LPA Jensen observed food in the refrigerator and freezer to have labels showing the date the food item was put in the refrigerator or freezer. LPA Jensen interviewed the Licensee who stated that food in the refrigerator is typically used the same day but discarded after 3 days if not used. The food in the freezer is also labeled on the date it is placed in the freezer then discarded if not used after 6 months. The labeling and storage time guidelines are in compliance.

Continued on LIC 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230918133223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
VISIT DATE: 10/05/2023
NARRATIVE
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Continued from LIC 9099...

LPA Jensen checked the kitchen pantry and did a random sampling of food items to check for expiration dates. LPA Jensen observed several canned items and dry goods to be expired including Mayonnaise, refried beans, tomato sauce, cranberries, soup, stuffing, salad dressing and meat marinades. As a result of the multiple canned and dry food items that were being stored past the expiration date the allegation of Facility foods are not properly stored is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

Technical assistance was provided on food storage timelines.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20230918133223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
87555(b)(9)
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General Food Service Requirements
The following food service requirements shall apply:
...Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met based on:
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The Licensee will implement a process wherein staff conducts monthly audits of food supplies and agrees to send an attestation by fax that this has been implemented by Plan of Correction due date.
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As evidenced by LPA Jensen's observation of multiple canned and dry food items that were in the kitchen pantry beyond and were past their expiration dates.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3