557000412-12-5-2023-27-AS-LRIS-CYP2J8-20231219162555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 12/05/2023
Date Signed: 12/05/2023 09:13:45 AM

Unsubstantiated

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
08/11/2023 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20230811113718

FACILITY NAME:	MEADOWVIEW MANOR		FACILITY NUMBER:	557000412
ADMINISTRATOR:	N/A		FACILITY TYPE:	740
ADDRESS:	19227 SOUTH COURT		TELEPHONE:	(209) 533-0935
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	20	CENSUS: 17	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Beatrice Burkett		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility is not allowing resident to have visitors.
Facility confiscated resident's food items.

INVESTIGATION FINDINGS:

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On 12/5/23 at approximately 8:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegtions. LPA Jensen met with Beatrice Burkett and explained the purpose of today's visit.

LPA Jensen requested and reviewed the resident file for R1. During the course of the investigation LPA Kimberly Viarella interviewed a facility staff member, the county Ombudsman, the responsible party for R1 and a relative of R1. LPA Jensen interviewed the Licensee.

The facility staff member stated that while visitation was not restricted, vistation in the morning and early afternoons was encourgaed as a result of R1 experiencing sun downing symptoms. The staff member also stated that any food items brought in by R1's visitors were kept in the kitchen and portioned out during the day in order to encourage healthy eating and sleeping habits.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20230811113718

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: 12/05/2023

NARRATIVE

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An interview with the responsible party for R1 who holds Power of Attorney (POA) revealed that the facility staff had discussed maintaining visiting hours prior to 3pm for R1 and limiting night time sweets in order to lessen sun downing symptoms. The responsible party for R1 had agreed to this course of action for R1's well being.

Based on interviews conducted and records reviewed, the allegation of the facility is not allowing resident to have visitors is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred the preponderance of evidence does not prove it. The facility staff, in collaboration with the R1's POA chose to restrict visiting hours in the interest of R1's well being.

Based on interviews conducted and records reviewed, the allegation of the facility confiscated resident's food items is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred the preponderance of evidence does not prove it. The facility staff stored R1's food items for them and distributed the food items in a manner consistent with the agreement made in conjunction with the POA.

No deficiencies are being cited as a result of this investigation. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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