557000412-1-26-2023-27-AS-APAA-CNFM45-20230126081608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 01/25/2023
Date Signed: 01/26/2023 08:16:13 AM

Document Has Been Signed on 01/26/2023 08:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	SHERIL DUPUICH		FACILITY TYPE:	740
ADDRESS:	19227 SOUTH COURT		TELEPHONE:	(209) 533-0935
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	20	CENSUS: 17	DATE:	01/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Sheril Dupuich		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/25/2023 at 10:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced at this facility to conduct an Annual Infection Control Visit. LPA Pascua was greeted by Facility Designated Administrator (FDA), Sheril Dupuich and explained the purpose of the visit. The Facility Designated Administrator currently holds an active Administrator's Certificate and expires on 08/05/2023. This facility holds a Dementia Plan on file and is able to serve 3 residents on hospice. There are currently 17 residents residing at this facility and At 11:00am, LPA Pascua initiated a tour of the facility with FDA Dupuich. The interior of the physical plant was toured and observed to be in good condition and sanitary. Fire extinguishers located in the kitchen and hallways appeared to have been annually inspected by Gateway Fire Inspection Company and is valid until January 31, 2023. LPA observed smoke detectors and carbon monoxide detectors to be operational. The facility also has fire sprinklers. The kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7-day non-perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in 2 additional large refrigerators located outside of the kitchen. Additional non-perishable food supply were also located in the cabinets. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the resident bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Two linen closets were located at the end of each hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/25/2023

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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time

The exterior of the physical plant was toured. LPA Pascua observed the outside resident area which appeared to be stable and in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 500

-LIC 610

-A copy of the Liability Insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to the Facility Designated Administrator, Sheril Dupuich.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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