306001145-8-26-2024-22-AS-JROO-D8HS7Z-20240826133823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001145
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:38:31 PM

Document Has Been Signed on 08/26/2024 01:38 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MEADOWLARK GARDENS V		FACILITY NUMBER:	306001145
ADMINISTRATOR:	WILKES, CHRISTINE M.		FACILITY TYPE:	740
ADDRESS:	17342 ZEIDER LANE		TELEPHONE:	(714) 840-1776
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	House Manager, Sharon Pajarillaga		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/26/24 Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios conducted an unannounced visit to the facility for a required annual inspection. LPAs met with the House Manager (HM) Sharon Pajarillaga, who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for five (5), and LPAs were informed two (2) residents are currently receiving hospice services at the facility. During today's visit, LPAs observed two (2) staff and six (6) residents present. LPAs toured the facility with HM Pajarillaga and observed the facility is made up of a one-story home with five (5) resident bedrooms, two (2) bathrooms, a staff room, kitchen, dining room, living room, and attached garage. During the tour, HM Pajarillaga tested one (1) of the smoke alarms/carbon monoxide detectors and LPAs observed it to be operational. LPAs also observed a charged fire extinguisher mounted near the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked kitchen closet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilets and in the showers. LPAs observed a hallway closet filled with clean linens and towels. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Staff present have a criminal record clearance and are associated with the facility. Complaint information is visibly posted near the front entrance. During a record review, LPAs reviewed Resident 1's (R1's) Physician's Report's (LIC 602A's) dated 6/26/23, 8/3/23 and 5/22/24, which identified R1 as bedridden and unable to independently transfer themselves to and from bed. LPAs also reviewed an LIC 602A dated 7/29/24, indicating R1 is non-ambulatory and unable to independently transfer themselves to and from bed. During the visit, LPAs observed HM Pajarillaga ask R1 to reposition themselves and LPAs observed R1 was unable to reposition themselves in bed. LPA's reviewed R1's Appraisal/Needs and Services Plan (LIC 625) which states R1 is bed bound.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEADOWLARK GARDENS V	FACILITY NUMBER: 306001145
	VISIT DATE: 08/26/2024

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LPAs reviewed R1's hospice care plan dated 7/30/24 which notes R1 requires repositioning every two (2) hours. LPAs reviewed R1's Home Health/Hospice Documentation dated 8/23/24, which states R1 is being turned every two (2) hours.

LPAs reviewed Resident 2's (R2's) LIC 602A dated 12/7/23 which notes R2 is non-ambulatory and unable to independently transfer themselves to and from bed. LPAs reviewed R2's hospice care plan dated 2/7/23, which indicates R2 requires repositioning every two (2) hours. LPA's reviewed R2's Home Health/Hospice Documentation dated 7/8/24, 7/22/24, 7/26/24, 8/1/24, 8/5/24, 8/9/24, 8/12/24, 8/16/24, 8/23/24 which note R2 requires continuous repositioning every two (2) hours. LPAs observed HM Pajarillaga ask R2 to reposition themselves and LPAs observed R2 was unable to reposition themselves in bed.

Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed and provided to HM Pajarillaga along with a Confidential Names List (LIC 811), LIC809-D and LIC421M and appeal rights.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEADOWLARK GARDENS V	FACILITY NUMBER: 306001145
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observatios, interviews conducted and records reviewed, the licensee did not comply with the section cited above accepting/retaining two (2) bedridden residents while having a fire clearance for non-ambulatory residents only, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee reported they will contact their local fire department and report the facility has two (2) bedridden residents. Licensee added R1 and R2 will be relocated to a facility with an appropriate fire clearance. POC to be submitted to LPA via email by close of business on 8/27/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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