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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
557000412
Report Date:
12/28/2023
Date Signed:
12/28/2023 03:17:25 PM
Document Has Been Signed on
12/28/2023 03:17 PM
- 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
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:
15
DATE:
12/28/2023
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Beatrice Burkett
TIME COMPLETED:
03:30 PM
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On 12/2823 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Bea Schoon and Administrator Beatrice Burkett. LPA Jensen explained the purpose of today's visit.
On 5/12/23 a non-compliance conference was held to discuss the following issues:
Facility staffing
Criminal Background Clearance/Fingerprint Clearance
Proper documentation of staff scheduled to work and be present in the facility
Personal Rights of the Residents
Personal Rights training and verification
Maintaining continued compliance
Oversight of facility staff for proper care and supervision
Reporting Requirements
This visit is being conducted to monitor compliance in these areas. There were 3 staff members on duty at the time of this visit. LPA Jensen reviewed training records. Training for Resident's Rights and Abuse Reporting was conducted on 12/27/23. LPA Jensen obtained a current copy of the LIC 500 which was updated 9-3-23. LPA Jensen reviewed the files 7 of 7 staff files and determined all to have criminal background clearance. LPA Jensen reviewed 5 resident files and confirmed all contained personal rights forms. Staffing was determined to be sufficient. LPA observed 15 of 15 residents and engaged with several.
No deficiencies were observed in the areas of focus at this time. An exit interview was conducted and a copy of this report and an LIC 811 was provided.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Maja Jensen
TELEPHONE:
(916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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