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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:31:54 PM


Document Has Been Signed on 03/19/2024 01:31 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 MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:N/AFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 17DATE:
03/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bea SchoonTIME COMPLETED:
01:45 PM
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On 3/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at a facility unannounced to conduct a case management visit related to an unwitnessed fall. LPA Jensen met with Licensee Bea Schoon and explained the purpose of the visit. The staff member on duty at the time of the fall was not currently working due to illness.

LPA requested a the resident file for resident 1 (R1). The facility has a large outdoor area with a combination of a raised wrap around patio, grass with landscaping and a cement driveway and walkway. The residnet was observed outside sitting on the sidewalk with minor injuries. Staff assisted R1 in to a chair and called 911 and called R1's responsible party.

LPA Jensen reviewed the facility file for R1. LPA Jensen reviewed the Needs and Service Plan. It was prepared on 2/7/24 but is not signed. The Needs and Service Plan from 2/7/24 states that R1 uses a walker and staff will monitor.

LPA Jensen reviewed the Pre-Placement appraisals which identifies a history of fall and that the resident is unable to navigate stairs without a rail.

Technical assistance is being provided in order to assist the facility in developing a plan to mitigate fall risk.

During the course of this visit it was also learned that the facility is experiencing a COVID outbreak. Technical assistance was provided based on the provider information notice issued on 3/11/24 and the LPA will return within the next week to provide PPE. LPA Jensen requested the Licensee notify the County Public Health Department regarding any existing or new COVID positive residents and staff.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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