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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:05:48 PM


Document Has Been Signed on 07/02/2024 01:05 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 MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:N/AFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 17DATE:
07/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Beatrice BurkettTIME COMPLETED:
01:15 PM
NARRATIVE
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On 7/2/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit related to unwitnessed falls. LPA Jensen met with Administrator Beatrice Burkett and Bea Schoon and explained the purpose of today's visit.

Over the course of the last 6 months, multiple residents have experienced unwitnessed falls that have resulted in significant injuries that include nasal fracture, skin avulsion, and facial trauma. Based on a record review the residents in question are identified as known falls risks. On 3/19/24 Licensing Program Analyst provided technical assistance regarding fall risk mitigation however residents have continued to experience injury inducing falls. LPA Jensen discussed the following fall risk mitigation strategies with the Administrator and Licensee:
-Increased staffing levels
-A robust activity program to keep clients engaged
-Use of lap buddies when warranted
-Medication changes
-Identifying triggers that cause anxiety or confusion
-Monitoring for urinary tract infections

The Licensee has indicated that an activity director was interviewed within the last week and employment is pending background clearance. LPA Jensen was also advised that resident 1 has also had a medication change within the last week in an effort to improve balance and coordination.

A deficiency is being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and confidential names list was provided.


SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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 2


Document Has Been Signed on 07/02/2024 01:05 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: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2024
Section Cited
CCR
87464(f)(1)

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Basic Services
asic services shall at a minimum include:

(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:

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The Licensee has already implemented measures for fall risk mitigation based on the case management that was commenced on 6/21/24 that include medication changes, hiring an activity director and use of lap buddies. The Administrator will also update R1's needs and service plan to detail all measures being taken.
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Based on incident reports submitted, photos reviewed and LPA Jensen's observation of residents with facial trauma. This poses a potential risk to the health, safety and personal rights of resdients in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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