<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701306
Report Date: 02/05/2025
Date Signed: 02/05/2025 03:52:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20250131133323
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
342701306
ADMINISTRATOR:SELLERS, ALYSSAFACILITY TYPE:
740
ADDRESS:9325 EAST STOCKTON BLVD.TELEPHONE:
(916) 877-7835
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 86DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alyssa SellersTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not report incidents to the Department in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/5/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct the initial complaint visit regarding the allegation noted above. LPA initially met with the Director of Health and Wellness, Ashley Melendez (DHW) and stated the purpose of the visit. The Adminsitrator, Alyssa Sellers (AD) was notified and arrived shortly after.

The investigation into the above allegation consisted of record review of written incident reports and staff interviews.

Record reviews of the incident reports submitted to (or received by) the Department over the past six months (from August 2024 to February 2025) reveals 13 instances where written reports were submitted later than the required seven-day reporting timeframe:

{con't to LIC9099-C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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 3
Control Number 27-AS-20250131133323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306
VISIT DATE: 02/05/2025
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
26
27
28
29
30
31
32
- Incident for Resident_1 (R1) on 7/20/24—reported on 8/2/24
- Incident for R2 on 7/22/24—reported on 8/2/24
- Incident for R3 on 7/22/24—reported on 8/2/24
- Incident for R4 on 7/22/24—reported on 8/2/24
- Incident for R5 on 8/26/24—reported on 9/4/24
- Incident for R6 on 9/2/24—reported on 9/10/24
- Incident for R7 on 10/22/24—reported on 10/30/24
- Incident for R8 on 10/6/24—reported on 10/16/24
- Incident for R9 on 10/7/24—reported on 10/16/24
- Incident for R7 on 10/17/24—reported on 10/25/24
- Incident for R10 on 11/4/24—reported on 11/12/24
- Incident for R11 on 11/12/24—reported on 11/20/24
- Incident for R12 on 1/5/25—reported on 1/13/25

Interview with the Director of Health and Wellness (DHW), Ashley Melendez, indicated that reportable incidents include hospitalizations, injuries, and death, and that the Administrator, Alyssa Sellers (AD), determines which incidents require reporting. However, the process of incident reporting, as explained by the staff, involves multiple steps of review and approval. For example, reports are written by the DHW, reviewed by the AD and sometimes forwarded to corporate for additional review before being submitted to the Department.

Interview with AD confirmed that those are not assessed as non-serious incidents, are not reported to the licensing agency. These are documented internally but not submitted as written reports to the licensing agency unless the incident is deemed significant by clinical staff.

Based on the information gathered, the allegation that the facility does not report incidents to the Department in a timely manner is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Note that failure to correct deficiencies may result in civil penalties.

Exit interview was conducted with Alyssa Sellers, AD and Laura Willingham, COO and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250131133323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2025
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
Reporting Requirement: 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)...report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
1
2
3
4
5
6
7
Per discussion, the Administrator and clinical staff will review reporting requirements.
Administrator will submit a written statement of acknowledgment of the regulation cited. Submit statement by POC due date.

8
9
10
11
12
13
14
This requirement as evidenced by:
Based on record review of incident reports whinin the past 6 months, 13 incidents reports were submitted to the Department past the 7 days reporting period. This poses a potential health, safety, and personal risks to persons in care.
8
9
10
11
12
13
14
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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3