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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200103
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:27:04 PM

Document Has Been Signed on 09/05/2024 02:27 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MEADOW CREEK HOMEFACILITY NUMBER:
079200103
ADMINISTRATOR/
DIRECTOR:		AIRA MANGASPARFACILITY TYPE:
735
ADDRESS:4805 WOODBRIDGE WAYTELEPHONE:
(925) 779-0931
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Aira Mangaspar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 09/05/24 at 12:10PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed ADM has current administrator certificate# 6050391735 which expires 12/16/2024.

At 12:25PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper handwashing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 107 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Two fire extinguishers were observed fully charged and last inspected on 08/01/24. LPA reviewed 5 staff and 5 client files. P&I monies were observed matching recorded logs and separate from facility funds.

Updated copies of the following documents were obtained from administrator:
 LIC500- Personnel Report
 Clients Roster
 LIC308- Designation of Facility Responsibility
 LIC610D- Emergency/Disaster Plan including infection control plans
 Evidence of Surety Bond

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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