557000412-6-6-2023-27-AS-CYAG-CSK29M-20230606171210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557000412
Report Date: 05/16/2023
Date Signed: 06/06/2023 05:12:13 PM

Document Has Been Signed on 06/06/2023 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 15	DATE:	05/16/2023
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheril Dupuich and Beatrice Schoon		TIME COMPLETED:	11:00 AM

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	A Non-Compliance Conference (NCC) was conducted on this day, 05/16/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after a complaint was filed and investigation completed. Present in the meeting was Licensing Program Manager (LPM) LPM Liza King, Regional Manager (RM) RM Stephenie Doub, Licensing Program Analyst (LPA) Charlie Yang, Licensing Program Analyst (LPA) Kimberly Viarella, and Facility Designated Administrator Sheril Dupuich with Licensee Beatrice Schoon. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. The focus of the concerns at this time: Facility staffing Criminal Background Clearance/Fingerprint Clearance Proper documentation of staff scheduled to work and be present in the facility Personal Rights of the Residents Personal Rights training and verification Maintaining continued compliance Oversight of facility staff for proper care and supervision Reporting Requirements

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWVIEW MANOR	FACILITY NUMBER: 557000412
	VISIT DATE: 05/16/2023

NARRATIVE

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Licensee agreed to do the following in order to bring the facility into compliance:

Complete and Submit the LIC 500 for the most current staff, shifts, and coverage

Complete and Submit the LIC 308

Complete and Submit proof of most recent training in the areas of Resident Personal Rights, Resident Care, and Resident Supervision. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees

Not withstanding the above statement, the Department will take the following actions:

The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance.
Facility designated Administrator has agreed to enroll and enlist services from TSP
Failure to maintain substantial compliance outlined on LIC 9111 dated 05/16/2023 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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