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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 01/28/2022
Date Signed: 02/01/2022 09:32:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 16DATE:
01/28/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sheril Dupuich - AdministratorTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analysts (LPA) Ruth Wallace conducted an unannounced Annual/Random Inspection. LPA met with Administrator Sheril Dupuich and discussed purpose of visit. Continual Administrator's Certification expires 08/05/2023. There are currently 16 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for two-day perishable and seven-day nonperishable.

LPA reviewed 2 two resident files and two staff files. All staff is fingerprint cleared and associated to facility. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

Fire extinguishers expired 1/13/2022. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 107.5 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.


Administrator qualifications is to follow all laws and regulations. None of the staff are vaccinated and Licensee agrees to have all staff get exemptions by 2/2/2022.
Deficiencies are cited from California Code of regulations, Title 22, Division 6, 8 and citation is listed on the attached LIC 809-D. One Immediate Civil Penalty Assessed of $500.00 each.

An exit interview was conducted with Administrator. Copies of reports, appeal rights, and civil penalty was left at the facility..

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation (The fire extinguishers tags expired 1/13/2022), the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2022
Plan of Correction
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Licensee agreed to purchase new fire extinguishers during LPA's inspection on 01/28/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)
Admiistrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of staff records, no staff are vaccinated; the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2022
Plan of Correction
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Licensee agrees to have all staff get exemptions sent via email to LPA by 2/2/2022.
ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3