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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603047
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:43:44 AM

Document Has Been Signed on 12/29/2022 10:43 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, 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: 3DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Samrach ChhuonTIME COMPLETED:
11:00 AM
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On 12/29/2022 at 9:30 am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit with a primary focus on infection control measures, using the new care tool. LPA was met by the Samrach Chhuon, staff, and the purpose of today’s visit was explained. The facility is licensed to serve 4 ambulatory residents 18 to 59 years of age. The facilities annual fees are current.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were also observed. The facility has the mandated COVID infection control posters. My temperature was taken at the entrance of the facility where there is a sanitizing station and a logbook for visitors to check in.

LPA Scott and Mr. Chhuon toured the facility. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. LPA Scott further observed the facility to be clean and appropriately furnished at the time of visit. Bathrooms were observed to be clean and operational. LPA observed that the fire extinguisher was fully charged and there were no bodies of water on the premises. All windows and window screens were in good condition. The water temperature was within guidelines and measured 113.9 degrees f. Smoke/Carbon monoxide detectors were operable. The last disaster drill was completed on 10/30/22.

Continued on LIC809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GREEN MEADOWS HOME II
FACILITY NUMBER: 198603047
VISIT DATE: 12/29/2022
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There are currently 4 residents in care. The facility is one-story structure with 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, sunroom, and patio. The backyard was free from any hazards or obstructions. LPA observed that the backyard was well-maintained with different types of fruit trees and a sitting area for the residents. LPA observed that the resident/staff files were maintained in a locked filing cabinet as well as all medications. Facility had required postings for employee rights, emergency contacts, personal rights, and house rules. The facility license was posted and current. The kitchen area was checked and in compliance with title 22. Perishable and non-perishables food supply was adequate at time of visit. All disinfectants, toxins, knives, and cleaning solutions were locked and inaccessible to residents.

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 that staff were wearing face coverings and had the required postings posted 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 Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies cited.


An exit interview was held, and a copy of the Facility Evaluation Report was provided to the Samrach Chhuon, staff.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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