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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 05/01/2023
Date Signed: 05/02/2023 04:48:20 PM


Document Has Been Signed on 05/02/2023 04:48 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MEADOWVIEW MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:SHERIL DUPUICHFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 17DATE:
05/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Beatrice Schoon and Sheril DupuichTIME COMPLETED:
03:30 PM
NARRATIVE
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On 05/01/23 Licensing Program Analyst, (LPA) Charlie Yang made an unannounced case management visit to open and follow up on an investigation conducted by the department (Complaint# 27-AS-2023042109491) . LPA identified himself upon arrival and explained the purpose of his visit. LPA met with the facility Licensee, Beatrice Schoon, and the facility designated Administrator, Sheril Dupuich, and the following information was provided.
On 04/20/23 The Department conducted an unannounced facility visit to follow up on an allegation that an excluded individual was employed at the facility.
Upon arrival, the Department requested to speak with the facility designated Administrator or Designee. Neither were available. The Department was informed that the Licensee had gone out of town and that the facility designated Administrator was on a cruise. In addition to the excluded individual referenced in the above complaint number, an individual, who represented themselves as a volunteer, (S3) was also present at the facility and was not fingerprint cleared. During the facility visit, the Department, asked the Licensee to seek replacement caregivers immediately. Approximately 40 minutes later an associated staff member (S2) arrived. The Department requested an LIC 500 which S1 was unable to provide. The facility caregiver, S2, arrived at the facility and was provided the immediate exclusion letter for SI. The facility staff person, S2, was unable to provide an LIC 500, however they wrote a partial list of staff names from payroll records to assist the department. While S2 was compiling the list of employees, S3 and S1 reported that they had just spoke to the License, via telephone, and she stated that she did not want S2 to go into her office and that she would be in shortly and would provide the list of names herself. The department advised staff that they should always know where the staff and resident rosters are, and that these documents must be made available to Licensing upon request. Four of the names from this list were not fingerprint cleared.
On 04/21/23 The Department contacted the Licensee via telephone, identified themselves and explained the reason for the call. The Department informed Licensee, “her staff should know where the staff and resident roster is always, and it should be made available to licensing upon visit.” A copy of the LIC 500 was provided via fax on this day. It also contained the names of two of the four individuals whom were not fingerprint
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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 5


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
VISIT DATE: 05/01/2023
NARRATIVE
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cleared from the handwritten list provided the day prior.

According to the California Code of Regulations (Title 22, Division 6), the LPA observed the following deficiencies listed on the following LIC 809 D.

Civil penalties were assessed in the amount of $1500 per the LIC 421 BG.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.



Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/02/2023 04:48 PM - 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: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/02/2023
Section Cited
CCR
87411(g)(1)

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Personnel Requirements - General
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations.
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Facility designated Administrator stated that all persons who are not fingerprint cleared and properly associated to this facility will be removed and not scheduled to be present or employed at this facility.
A statement of correction, along with proof of review for this section cited, 87411(g)(1), will be completed and submitted into CCL by the
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This regulation was not met as evidenced by:
Based on SI’s acknowledgement of exclusion status, documentation review, facility observations and interviews. This posed an immediate health, safety or personal rights risk to persons in care.
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due date.
Type A
05/08/2023
Section Cited
CCR87405(d)(2)

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Administrator Qualifications
The administrator shall have…(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This regulation was not met as evidenced by:
Based on observation of individuals present in the facility without a criminal record clearance, the lack of an Administrator or designee and
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Facility designated Administrator stated that the facility will be properly staffed with a certified Administrator at all times. A back up certified Administrator will be made available and CCL will be informed when the facility designated Administrator will not be present for an extended period of time away from this facility.
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interviews with staff regarding the lack of accessibility of licensing required documents. The administrator was not conforming to applicable laws, rules and regulations, which posed an immediate health, safety or personal rights risk to persons in care.
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A statement of correction, along with proof of review for this section cited, 87405(d)(2), will be completed and submitted into CCL by the due date.
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) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/02/2023 04:48 PM - 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: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2023
Section Cited
CCR
87205(a)

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Accountability of Licensee Governing Body The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
This regulation was not met as evidenced by:
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Facility designated Administrator stated that the facility will be properly staffed with a certified Administrator at all times. A back up certified Administrator will be made available and CCL will be informed when the facility designated Administrator will not be present for an extended period of time away from this facility.
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Based on interview, the licensee reported and had knowledge that the one staff member had been employed at the facility for one month and had not been fingerprinted, which posed an immediate health, safety or personal rights risk to persons in care.
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A statement of correction, along with proof of review for this section cited, 87205(a), will be completed and submitted into CCL by the due date.
Type A
05/08/2023
Section Cited
CCR87468(a)(2)

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Personal Rights – (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:…(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This regulation was not met as evidenced by:
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Facility designated Administrator stated that the facility will be properly staffed with properly fingerprint cleared and associated staff at all times.
A statement of correction, along with proof of review for this section cited, 87468(a)(2), will be completed and submitted into CCL by the due date.
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Based on interview with the licensee, residents were cared for by an individual with a criminal history placing them in potential danger. The other individual whom were present had no criminal record clearance. This posed an immediate health, safety or personal rights risk to persons 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) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/02/2023 04:48 PM - 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: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited
CCR
87412(f)

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Personnel Records
All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
This regulation was not met as evidenced by:
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Facility designated Administrator stated that all facility personnel will be in serviced, for no less than (1) hour in duration, on the training issues of maintaining facility documentation, knowledge of storage with facility staff/resident files, and submission of facility records to licensing personnel upon request for review.
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Based on interview of staff and the licensee, personnel reports were not made available for licensing’s review during the facility visit. This posed a potential health, safety or personal rights risk to persons in care.
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A statement of correction, along with proof of facility personnel training topics covered, attendees, and trainer for this section cited, 87468(a)(2), will be completed and submitted into CCL by the due date.

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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) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5