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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204907
Report Date: 11/20/2024
Date Signed: 11/22/2024 08:23:31 AM

Document Has Been Signed on 11/22/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GREEN MEADOWS BOARD AND CARE 11FACILITY NUMBER:
198204907
ADMINISTRATOR/
DIRECTOR:		ELLEN CASTILLOFACILITY TYPE:
740
ADDRESS:1595 OAKHORNE DRIVETELEPHONE:
(310) 325-8883
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:51 AM
MET WITH:ADMINISTRATOR ELLEN CASTILLOTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 11/20/2024 at 11:30 AM, Licensing Program Analyst LPA Jose Calderon conducted an unannounced annual inspection visit at the Green Meadows Board and Care II Facility. LPA Calderon was allowed entry into the facility by Administrator Ellen Castillo. Administrator Castillo asked infection control questions and took LPA Calderon temperature prior to entering the facility. The facility is licensed to operate for six (6) non-ambulatory residents ages 60 and above. Currently, there are five (5) residents residing in the facility, between the age of 60 and above.

LPA Calderon explained to Administrator Castillo, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) resident service records, five (5) resident medication records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed five (5) residents and two (2) staff members for visit. The facilities’ last fire drill was conducted on 11/12/2024. The one-story residential home consists of five (5) resident bedrooms, two (2) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored or found on the premise grounds. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage.
Ulysses CoronelTELEPHONE: (323) 400-7397
Jose CalderonTELEPHONE: (323) 213-1153
DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN MEADOWS BOARD AND CARE 11
FACILITY NUMBER: 198204907
VISIT DATE: 11/20/2024
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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 117 degrees Fahrenheit; bathroom #2 hot water temperature properly measured at 120 degrees Fahrenheit. Kitchen hot water temperature properly measured at 117 degrees Fahrenheit. Facility two (2) Carbon Monoxide and seven (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility two (2) Fire Extinguisher was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility two (2) first aid kits is fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Five (5) resident files were reviewed and found to be complete. LPA Calderon reviewed five (5) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Ellen Castillo Certification # 7007388740 expiration date of 02/20/2025 was valid at time of inspection. The facility does not handle client's money/cash resources and no Surety bond is needed. Commercial General Liability Policy #ADMINISTRATOR COULD NOT PRODUCE INSURANCE PAPERWORK AT THIS TIME. Administrator Ellen Castillo to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 11/22/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN MEADOWS BOARD AND CARE 11
FACILITY NUMBER: 198204907
VISIT DATE: 11/20/2024
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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and clients were NOT wearing face coverings. LPA Calderon observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Ellen Castillo to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Ellen Castillo.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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