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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:30:51 PM


Document Has Been Signed on 06/21/2024 04:30 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: 19DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Beatrice BurkettTIME COMPLETED:
04:30 PM
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On 6/21/24 at approximately 2:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with acting Administrator Beatrice Burkett and explained the purpose of today's visit.

During the course of the visit LPA Jensen observed a resident (R2) that appeared to have sustained a fall. LPA Jensen took a photo of the resident with the resident's permission. LPA Jensen also took photos of resident file documentation including the LIC 602, pre-placement appraisal, needs and service plan and incident reports. Due to time constraints this case management will require additional time to complete. An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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