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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 11/15/2022
Date Signed: 11/16/2022 11:29:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220719121508
FACILITY NAME:MEADOWVIEW MANORFACILITY NUMBER:
557000412
ADMINISTRATOR:SHERIL DUPUICHFACILITY TYPE:
740
ADDRESS:19227 SOUTH COURTTELEPHONE:
(209) 533-0935
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:20CENSUS: 16DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sheril Dupuich and Bea SchoonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not providing appropriate supervision
Tampering with records
Facility is not conducting proper COVID screening
INVESTIGATION FINDINGS:
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On 11/14/2022 at 10:15am, Licensing Program Analysts (LPA's) Arielle Pascua and Ruth Wallace arrived unannounced for a complaint visit. LPAs met with Licensee Bea Schoon and Administrator Sheril Dupuich and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegations above.
During the course of this investigation LPA Pascua conducted several interviews and reviewed several facility documents.
Allegation: Staff are not providing appropriate supervision
Based on interviews conducted it was learned that there was in incident between R1 and R2. The facility did not provide an incident report to the department regarding R1 and R2 at the time of occurence. LPA Pascua interviewed AD Dupuich and it was stated that this incident happened several times during the last couple of months. LPA Pascua also reviewed physicans reports for R1 and R2 and both residents were diagnosed with Dementia. Based on interviews and document review the facility did not provide appropriate supervison for R1 to protect the other residents from their personal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
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
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-20220719121508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEADOWVIEW MANOR
FACILITY NUMBER: 557000412
VISIT DATE: 11/15/2022
NARRATIVE
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Allegation: Tampering with records
Based on interviews and document review it was learned that the facility holds a notebook that maintains the residents progress notes and daily activities. LPA Pascua reviewed facility records and it was observed that parts of the notebook for resident notes were cut out on 04/26/2022, 05/14/2022, 06/12/2022, and 07/06/2022. LPA Pascua interviewed the Licensee Schoon and Administrator Dupuich and it was stated that S1 wrote in the book that they witnessed an incident between R1 and R2. Licensee Schoon and AD Dupuich stated that when they questioned S1 about what was written S1 cut out pieces of the notebook. Based on interviews and document review the facility did not ensure that there were continued records for R1's needed services.

Allegation: Facility is not conducting proper COVID screening.
During the course of this interview LPA Pascua conducted a tour of a facility. Upon arrival LPA Pascua observed that the facility does not have a COVID-19 Precautionary visitor sign in log/book. LPA Pascua interviewed Administrator (AD) Sheril Dupuich. AD Dupuich stated that they have stopped COVID screening for a couple months now and do not need to provide COVID screening to visitors because they are aware not to come into the facility if they are not feeling well. Based on observation the facility did not provide a centralized COVID screening point for facility visitors.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
An Exit Interview was conducted a copy of the 9099, 9099-C, 9099-D and appeals rights were provide to Facility Administrator, Sheril Dupuich.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220719121508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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
HSC
1569.50(a)(3)
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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:
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Licensee/Administrator agrees to train all staff on COVID-19 precautionary measures by POC Date 11/16/2022. Facility staff agrees to implement COVID 19 pre-screening measures at entrance of facility and implement a COVID-19 Visitor Log/Book by POC Date 11/16/2022.
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Based on observation the facility does not have a centralized screening point for proper COVID screening. This poses an immediate health, safety, and personal rights risks to the persons in care.
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Type A
11/16/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights
Each client has the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This is not as requirement was not as evidenced by:
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Licensee/Administrator agrees to provide personal rights training and agrees to email LPA Pascua personal rights training documents by POC date 11/16/2022 by close of business at 5:00pm.
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R1's behavior poses risk and has become a danger to the other clients in care. The facility did not provide a safe environment. This poses an immediate health, safety, and resident rights risk for residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220719121508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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
CCR
87211(a)(1)
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87211 Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This is requirement was not met as evidenced by:
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Licensee/Administrator agrees to provide a signed and dated stated of understanding of the CCR 87211 (a)(1) and sumbit it to LPA Pascua's email by POC date 12/15/2022.
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Based on interview and record review, the facility has not provided any incident reports to the department. This poses a potential health, safety, and resident rights risk for residents in care.
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Type B
12/15/2022
Section Cited
CCR
87506(b)(13)
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87506Resident Records
(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement was not met as evidenced by:
Based on interview and record review the
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Licensee/Administrator agrees to provide a signed and dated statement of understanding of the CCR 87506(b)(13) and ensure that all residents records remain on file. Licensee/Administrator also agrees to provide a plan to mitigate's R1's behavior. The POC will submitted to licensing by 12/15/2022.
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facility did not ensure that the continued record was current for R1's needed services. This poses a potential health, safety, and resident rights risk for residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4