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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001145
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:37:56 PM


Document Has Been Signed on 05/06/2022 02:37 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MEADOWLARK GARDENS VFACILITY NUMBER:
306001145
ADMINISTRATOR:WILKES, CHRISTINE M.FACILITY TYPE:
740
ADDRESS:17342 ZEIDER LANETELEPHONE:
(714) 840-1776
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:House Manager, Sharon Pajarillaga and Administrator Sarah WilkesTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

At 1:20 PM LPA toured the facility with Caregiver Julieta Salo. During visit House Manager Sharon Pajarillaga and Administrator Sarah Wilkes arrived during visit. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 2 bathroom single story home. There are 6 Residents in care. LPA observed proper Covid signage at front entrance of facility as well as a sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 9/7/2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and a working water basin. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV. Facility has smoke detectors, carbon monoxide detector and audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguisher which is mounted and fully charged. Facility has emergency food and water supply. Facility has supply of PPE. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for residents. LPA reviewed residents files during visit. LPA reviewed 6 of 6 resident files. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with House Manager and Administrator. A copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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