Community Care Licensing

SUPERVISOR'S NAME: Stephen Richardson TELEPHONE: (916) 253-4746 LICENSING EVALUATOR NAME: Ruth Wallace TELEPHONE: (619) 323-4509 LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022

Document Has Been Signed on 11/15/2022 04:17 PM - It Cannot Be Edited

FACILITY NAME: MEADOWVIEW MANOR	FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2022 Section Cited	1 2 3 4 5 6 7	87355(b) Criminal Record Clearance. (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This is not met by evidence by:
	8 9 10 11 12 13 14	Based on LPA record review licensee did not ensure that S4 have fingerprint clearance in order to work in the facility which poses an immediate health, safety, and personal rights risk for persons in care.	8 9 10 11 12 13 14
Type B 12/15/2022 Section Cited	1 2 3 4 5 6 7	87411(f) Personnel Requirements All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This is not met by evidence by:
	8 9 10 11 12 13 14	Based on LPA record review all staff are missing verified health screens and tuberculosis results. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Stephen Richardson TELEPHONE: (916) 253-4746 LICENSING EVALUATOR NAME: Ruth Wallace TELEPHONE: (619) 323-4509 LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022

Document Has Been Signed on 11/15/2022 04:17 PM - It Cannot Be Edited

FACILITY NAME: MEADOWVIEW MANOR	FACILITY NUMBER: 557000412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/15/2022 Section Cited	1 2 3 4 5 6 7	97411(c) (1) Personnel Requirements All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This is not met by evidence by:
	8 9 10 11 12 13 14	Based on LPA record review all staff are missing current first aid certificates. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
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SUPERVISOR'S NAME: Stephen Richardson TELEPHONE: (916) 253-4746 LICENSING EVALUATOR NAME: Ruth Wallace TELEPHONE: (619) 323-4509 LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022