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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603047
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:45:43 PM

Document Has Been Signed on 12/20/2021 01:45 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GREEN MEADOWS HOME IIFACILITY NUMBER:
198603047
ADMINISTRATOR:OM, RAKSMIEFACILITY TYPE:
735
ADDRESS:24225 POSTMASTER AVETELEPHONE:
(310) 871-4219
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 4CENSUS: 4DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR RAKSMIE OMTIME COMPLETED:
11:00 AM
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On 12/20/2021 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by Administrator Raksmie Om and the purpose of today’s visit was explained. The facility is licensed to serve 4 elderly 18 to 59 years or older.

There are currently 4 residents in care. There are 4 ambulatory clients in care. The facility is a one-story
structure with 4 bedrooms and 2 bathrooms, living room, kitchen, dining room, sun room and patio/back
yard. The back yard is wide open, with fruit trees and no water sources were found.

LPA Calderon and Administrator toured the physical plant. There are no bodies of water or
firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good
condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit.. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon
observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal
hygiene, cleaning agents, toxins, and sharps were not accessible to clients and locked in a cabinet. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GREEN MEADOWS HOME II
FACILITY NUMBER: 198603047
VISIT DATE: 12/20/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for
visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff
and residents were wearing face coverings, an isolation room and required postings throughout the facility.
LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and
Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19
guidance.

During today’s visit there were no deficiencies observed under California code of regulation title 22, division 6, chapter 8.

Exit interview held. A copy of the report was provided to Administrator Raksmie Om.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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