557000412-9-19-2023-27-AS-KVIA-CVT7BB-20230918213053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 09/18/2023
Date Signed: 09/19/2023 08:20:41 AM

Document Has Been Signed on 09/19/2023 08:20 AM - 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 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:	09/18/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bean Schoon, Licensee		TIME COMPLETED:	01:50 PM

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On 09/18/2023, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced quarterly case management visit to this facility. Upon arrival the LPA identified herself and the purpose of the visit and asked to meet with the Licensee, Bea Schoon. The focus of today's visit was to review the following:

Licensee agreed to do the following in order to bring the facility into compliance:

Complete and Submit the LIC 500 for the most current staff, shifts, and coverage
Complete and Submit the LIC 308
Complete and Submit proof of most recent training in the areas of Resident Personal Rights, Resident Care, and Resident Supervision. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees

Not withstanding the above statement, the Department will take the following actions:

The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance.
Facility designated Administrator has agreed to enroll and enlist services from TSP
Failure to maintain substantial compliance outlined on LIC 9111 dated 05/16/2023 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.

LPA was provided with a current staff schedule, with shifts, and coverage upon request. This roster did not match the roster in Guardian, however it did list new caregivers who have past their background checks. One was still listed as pending in LIS, however, documentation was provided by the Licensee showing that the new hire was recently associated to this facility. LPA provided the Guardian email address and phone number so that in the future, if the Licensee or Administrator have questions, they may contact Guardian directly. Guardian@dss.ca.gov or (888) 422-5669.
A new LIC 308 was provided with the caregiver/ Administrator candidate for Designated Facility Administrator listed as the designee.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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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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: 09/18/2023

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Licensee provided the LPA with documentation proving that Adventist Health Home Care facilitated a 90 minute training on 08/17/2023. The facilitator was Catherine Driver and the training reviewed myths about the services home health care provides. Five caregivers attended the in-service. A copy of the outline was provided to this LPA along with a list of potential in-services the Licensee was considering for the future. LPA reminded Licensee that the trainings were supposed to target listed the areas listed from the previous conference. The License agreed to provide those trainings next, (areas of: Resident Personal Rights, Resident Care, and Resident Supervision). Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees

Licensee also communicated to the LPA that they have a current resident who will be transitioning to hospice. The facility has a hospice waiver for 3 and they will not need a waiver increase or exception. LPA appreciated the notification.

LPA observed that the facility was still operating without a certified Designated Facility Administrator. The Licensee has made progress toward filling this position. One of the current employees has completed all of the course work and was scheduled to take the administrator's certification exam on September 13 online. On that day there was a county-wide power outage beginning at 1:08 PM and the power was not re-established until 8:30 PM. Caregiver provided LPA with an online article from Grayson Collin Electric Cooperative as proof of outage. The Administrator / candidate notified this LPA and informed the LPA that the new test date will be 09/20/23 at 1:30 PM. At the present time the facility does not have a certified Administrator.

This deficiency was cited on the LIC 809D page and civil penalties were assessed.

A copy of this report was provided along with Appeal Rights.

Exit interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 08:20 AM - 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: 09/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/18/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	(a) All facilities shall have a qualified and currently certified administrator.,. The administrator shall have... freedom from other responsibilities and shall be on the premises a require that the administrator devote... to fulfill responsibilities... This regulation was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall have the caregiver / administrator candidate take the Administrator Certifcation exam on 09/20/2023. The Licensee shall then submit a letter to kimberly.viarella@dss.ca.gov with proof that the exam has been coompleted and that they have an Administrator's position
	8 9 10 11 12 13 14	Based on observation and interview, the facility failed to provide a certified administrator. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	available. The LPA will forward the request to the Regional Office Manager for consideration.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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