557000412-5-2-2023-27-AS-KHOS-CTFKXP-20230705081752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557000412
Report Date: 05/01/2023
Date Signed: 05/02/2023 04:49:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
04/21/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230421094911

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:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Beatrice Schoon and Sheril Dupuich		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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RSO who is not a client allegedly resides, is present and/or has contact that may pose a risk to the health and safety of clients in care

INVESTIGATION FINDINGS:

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On 05/01/23 Licensing Program Analyst, (LPA) Charlie Yang conducted an unannounced complaint visit in regards to a complaint investigation with the above allegation. LPA identified himself upon arrival and explained the purpose of his visit. LPA met with the facility Licensee, Beatrice Schoon, and the facility designated Administrator, Sheril Dupuich, and the following information was provided.
On 04/20/23 The Department conducted an investigation to follow up on reports that an excluded individual was employed and present at this facility.
Upon arrival, the Department requested to speak with the Facility Designated Administrator or Designee. Neither were available. The Department was informed that the Licensee had gone out of town and that the facility designeated Administrator was on a cruise at this time. The Department observed the excluded individual (SI) present and employed by this facility and confirmed a history of a felony count against a minor. The Department presented SI with the Individual Exclusion Letter and asked them to sign a copy as proof of receipt. Interview with the facility licensee, Beatrice Schoon, via telephone confirmed that SI had been employed at the facility for approximately 1 month and fingerprints had not been done yet.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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-20230421094911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/01/2023

NARRATIVE

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During the facility visit, the Department, asked SI to vacate the premises, and informed the Licensee to seek replacement caregivers immediately. Approximately 40 minutes later a facility associated staff member (S2) arrived. The facility was provided a copy of the immediate exclusion letter for SI and requested a signature as receipt.

Based on SI’s acknowledgement of the exclusion status, documentation review, facility observations and interviews, the preponderance of the evidence standard had been met, therefore the above allegation was found to be SUBSTANTIATED.

The following deficiencies were observed and cited according to the California Code of Regulations (Title 22, Division 6) on the following LIC 9099-D.

Civil penalties were issued in the amount of $500 per the LIC 421 BG.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230421094911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/02/2023 Section Cited CCR 87411(g)(1)	1 2 3 4 5 6 7	Personnel Requirements - General Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1)Obtain a California clearance or a criminal record exemption as required by law or Department regulations.	1 2 3 4 5 6 7	Facility designated Administrator stated that all persons who are not fingerprint cleared and properly associated to this facility will be removed and not scheduled to be present or employed at this facility. A statement of correction, along with proof of review for this section cited, 87411(g)(1), will be completed and submitted into CCL by the
	8 9 10 11 12 13 14	This regulation was not met as evidenced by: Based on SI’s acknowledgement of exclusion status, documentation review, facility observations and interviews. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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