557000412-7-15-2024-27-AS-LRIS-D7YS3G-20240809133105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:37:47 PM

Substantiated

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
07/15/2024 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20240715095813

FACILITY NAME:	MEADOWVIEW MANOR		FACILITY NUMBER:	557000412
ADMINISTRATOR:	N/A		FACILITY TYPE:	740
ADDRESS:	19227 SOUTH COURT		TELEPHONE:	(209) 533-0935
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	20	CENSUS: 17	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Bea Schoon		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff allowed person without clearance to work at facility
An excluded individual was allowed in the facility

INVESTIGATION FINDINGS:

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On 7/15/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Administrator Bea Schoon and explained the purpose of today's visit.

Allegation 1: Staff allowed person without clearance to work at facility
During the course of the investigation LPA Jensen conducted interviews in person and by phone. LPA Jensen interviewed 2 current staff members, 1 former staff member, the Licensee and the Administrator. It was confirmed by 4 of 5 parties interviewed that staff 1 (S1) has worked at the facility. LPA Jensen verified through Guardian that S1 does not have a criminal background clearance. LPA Jensen also observed a list with several staff names and phone numbers on it including S1's name posted on the wall in the kitchen next to the Licensee's private office/living quarters. A photograph of the list was taken. Based on the interviews conducted and document observed, the allegation of staff allowed person without clearance to work at facility is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240715095813

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: 07/15/2024

NARRATIVE

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A finding of substantiated means that the preponderance of evidence standard has been met.

Allegation 2: An excluded individual was allowed in the facility:
LPA Jensen conducted interviews with 2 current staff members, a former staff member, and the Licensee. The Licensee, a current staff member and a former staff member all confirmed the presence on the premises of a person subject to a department Order of Exclusion. According to the Licensee, the excluded individual was on the premises strictly for the purposes of taking a shower due to a problem with the water at their own home. Based on the interviews conducted the allegation of an excluded individual was allowed in the facility is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited pursuant to the California Code of Regulations. Civil penalties are also being assessed. Further administrative actions may be considered and pursued.

An exit interview was conducted and a copy of this report, appeal rights and an LIC 811 was given.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240715095813

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2024 Section Cited CCR 87355(e)	1 2 3 4 5 6 7	Criminal Record Clearance All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... (2) Request a transfer of a criminal record clearance ... (3) Request and be approved for a transfer of a criminal record exemption, ... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to immediately cease use of any staff that does not have a criminal background clearance.
	8 9 10 11 12 13 14	As evidenced by interviews conducted and the Licensee's own admission S1 worked at the facility without a criminal backgroud clearance. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type A 07/16/2024 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to cease allowing access to the facility to any excluded individuals immediately.
	8 9 10 11 12 13 14	Based on interviews conducted and the Licensee's own admission, an excluded party was permitted on the premises. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14

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 Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

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