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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:22:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240405091022
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
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Beatrice BurkettTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff does not treat residents with dignity or respect
Staff do not ensure that the facilities food supply is of good quality

INVESTIGATION FINDINGS:
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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 compliant investigation in to the above listed allegations. LPA Jensen met with acting Administrator Beatrice Burkett and explained the purpose of today's visit.

Staff does not treat residents with dignity or respect
During the course of the investigation LPA Jensen interviewed 10 residents and 2 family members of a resident. None of the residents interviewed complained about feeling disrespected or not being treated with dignity. The family members interviewed also had no complaints about the residents being disrespected or treated in an undignified manner. During the course of 2 visits LPA Jensen observed staff interacting with residents in a respectful and dignified manner. While it is possible a resident was treated in a manner that could be interpreted as disrespectful or undignified at some point in time, based on the interviews conducted and LPA Jensen's observations the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20240405091022
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/21/2024
NARRATIVE
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Staff do not ensure that the facilities food supply is of good quality
During the course of this investigation LPA Jensen inspected the food supply on 2 separate occasions. LPA Jensen did not observe any expired food. LPA Jensen did observe fruit and vegetables that appeared to be of good quality. LPA Jensen observed meal service on 2 separate occasions and snacks being served. The meals observed were balanced and included protein, starch, fruit and vegetables. LPA Jensen also observed freshly baked cookies being served for snack. LPA Jensen also interviewed 10 residents, none of which stated the food was of poor quality. While it is possible that there may have been an occasion wherein there was expired food or spoiled food on site there was no evidence found that it was served to residents. Based on LPA Jensen's observations of the food supply, observation of meal service and interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report, appeal rights 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240405091022

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
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing resident with comfortable living accommodations
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/21/24 at approximately 2:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPA Jensen met with acting Administrator Beatrice Burkett and explained the purpose of today's visit.

Staff are not providing resident with comfortable living accommodations.
On 2 separate occasions LPA Jensen inspected the common areas of the facilities and the individual bedrooms. All residents had adequate furnishings. On 4/11/24 LPA Jensen observed one resident (R1) that has only a mattress on the floor. LPA Jensen reviewed a physician's assistant's order permitting the bed to be on the floor. On 6/21/2024 LPA Jensen observed R1's mattress to be on a box spring on the floor. LPA Jensen asked R1 if her bed was comfortable to which she replied 99% of the time. Based on LPA Jensen's observation of the facility furnishings, the interview with R1 and the review of the physician's order the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4