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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701306
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:42:42 PM

Document Has Been Signed on 07/01/2025 04:42 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
342701306
ADMINISTRATOR/
DIRECTOR:		SELLERS, ALYSSAFACILITY TYPE:
740
ADDRESS:9325 EAST STOCKTON BLVD.TELEPHONE:
(916) 877-7835
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 160CENSUS: 87DATE:
07/01/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:36 PM
MET WITH:Alyssa SellersTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 7/1/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a case management visit. LPA met with Executive Director/Administrator Alyssa Sellers and stated the purpose of the visit.

The purpose of this visit is to follow up on the death of Resident_1(R1) occurred on 6/21/25. The Department an incident report and death report on 6/27/25. The investigation into R1’s death consisted of interviews and record reviews. Per review of the death report, the cause of death is unknown at this time. Additionally, R1 was receiving hospice care services due to Alzheimer's Disease. R1 was sent to the hospital on 6/21/25 due to shortness of breath and low oxygen saturation.

According to an interview with the facility's Director of Health and Wellness (DHW), R1's family has not shared any updates about the cause of death. The DHW stated that R1 was removed from life support at the hospital, according to family member.


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Also, in this visit, LPA conducted a physical walk through of common areas both in the Assisted Living side and Memory Care side for complaint # 27-AS-20250625155709. During the walk through of the Memory Care Living room, LPA observed a cleaning chemical spray bottle labeled POPCORN MACHINE CLEANER inside a cabinet, above the faucet to the left. The cabinet was observed to be unlocked and the cleaning supply was accessible to residents in care. However, the bottle was located at the very top of the shelf. Additionally, LPA observed a staff to be present providing supervision to the residents in the room.

Based on this case management visit, deficiency is being cited.

Exit interview was conducted and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/01/2025 04:42 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/01/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
87309(a)

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(a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Per discussion, the Executive Director/Administrator will conduct an in-service training relating to the cited regulation. Proof of training to be submitted to the Department by POC due date.
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This requirement is not met as evidenced by:
Based on observation, a cleaning sulutions was observed in an unlocked cabinet in the Memory Care Livingroom area which was made accessible to residents in care. This poses a potential health, safety and personal risks to 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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