557000412-1-30-2024-27-AS-MJEN-CZZ252-20240130160449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:05:04 PM

Document Has Been Signed on 01/30/2024 04:05 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: 16	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Beatrice Burkett		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/30/23 Licensing Program Manager (LPM) Lisa Rios and Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Administrator Beatrice Burkett and explained the purpose of today's visit. The Administrator was handed an entrance checklist upon LPA's arrival. The current census is 16. During the course of the inspection LPA Jensen toured the grounds and observed all pathways to be clear of obstruction. All window screens were in good repair. There are shaded areas and outdoor furniture for client enjoyment. LPA Jensen toured the interior of the physical plant. The facility was observed to be sanitary and free of odor. There was adequate furnishings and lighting throughout. The facility maintains an adequate supply of linens. All medications, toxins and cleaning supplies were observed to be locked and inaccessible to residents in care. A first aid kit is maintained on site that is complete and in compliance. The bedrooms were observed to contain a chair, dresser, night stand lamp for each individual residing in the home. The bathrooms were observed to equipped with grab bars and non-slip flooring in the shower or bath. The water temperature in the bathroom 6B measured at 124 degrees Fahrenheit. LPA Jensen toured the kitchen and observed in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was fresh produce available. There was no expired food observed. The menu was posted in a location easily viewable by residents. LPA Jensen reviewed the emergency disaster plan and determined it to be in current and in compliance. The fire extinguisher was last serviced in January of 2024 and is in compliance. The carbon monoxide detectors were tested and determined to be in good working order. Emergency lighting is maintained on site and the facility has a generator for use in the event of a power outage. LPA Jensen engaged with several residents and conducted interviews with 2 residents. 2 of 2 residents stated they were satisfied with all aspects of their care. LPA Jensen interviewed 1 staff member that was able to answer competently. Continued on LIC 809C....

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/30/2024

NARRATIVE

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LPA Jensen reviewed 3 resident files. 1 of 3 resident files contained an LIC 602 that was not completed within the last 6 months. Technical assistance was provided. 1 of 3 resident files contained an LIC 602 that was not signed or dated by the resident representative. 3 of 3 resident files did not contain a Needs and Service Plan. The facility previously engaged in the Department's Technical Support Program (TSP) and requirement for Needs and Service Plans was discussed - see TSP Engagement Summary dated 1/2/24. LPM Rios reviewed 3 of 6 staff files. 1 of 3 staff files did not contain current first aid training. The Licensee Bea Schoon advised the staff member in question is infrequently scheduled. Technical assistance was provided.

The facility maintains supplies for a variety of activities. An activity calendar is posted in a location that is easily viewable by residents. Activities include exercise, Bingo, Dance/Music. There is a beauty salon on site.
LPA Jensen requested and received an LIC 500 and the current liability insurance. The inspection tool was used during the course of this inspection.

An exit interview was conducted with Beatrice Burkett and a copy of this report, an LIC 811 and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2024 04:05 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWVIEW MANOR	FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensens review of 3 resident files, the licensee did not comply with the section cited above in 3 out of 3 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The Licensee agrees complete Needs and Service Plans for all residents and send proof of correction to the Department by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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