306002886-7-23-2021-22-AS-SFRK-C57P53-20210723110000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002886
Report Date: 07/22/2021
Date Signed: 07/23/2021 11:00:04 AM

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 I		FACILITY NUMBER:	306002886
ADMINISTRATOR:	CHRISTINE WILKES		FACILITY TYPE:	740
ADDRESS:	5912 MIDIRON CIRCLE		TELEPHONE:	(714) 840-1776
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92649
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Rose Enriquez- Administrator		TIME COMPLETED:	10:45 AM

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	Licensing Program Analyst (LPA), Shobhana Frank , made an unannounced visit to the facility to conduct a required - 1 Year inspection. LPA Frank was granted entry into the facility by Care staff Sharon Pajarillaja. LPA Frank reviewed the facility file, reviewed Mitigation plan – LIC 808 –Mitigation Plan prior to visit. LPA complete Facility Risk Assessment prior to the visit. A tour of the facility was conducted inside and out of physical plant. 2 staff and 6 residents were present at the time of inspection. Facility has a capacity of six (6) residents, ages sixty (60) and above. The facility is operating in the capacity and conditions approved by CCL. There is no pool or bodies of water accessible to residents in care. Facility is a single story structure which has the capacity of retaining 6 residents. This facility has 7 bedrooms and 3 bathroom, 6 private bedrooms and 1 staff bedroom. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log. LPA observed COVID posters throughout the facility. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 108.3 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap, Sufficient PPE supplies and other chemicals in the garage. On 7/21/21 facility conducted surveillance Testing and results are negative. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed two staff file two resident file, two clients interviews were conducted. facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEADOWLARK GARDENS I	FACILITY NUMBER: 306002886
	VISIT DATE: 07/22/2021

NARRATIVE

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Personnel Records/Training/and Staffing- LPA reviewed two employee records. CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is present.

Food Service- The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair.

Fire extinguishers are charged, mounted and expires on 11/30/22 All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. The facility does not handle resident money.

Based on the information received during this visit today, there are no deficiencies being cited in the area inspected.
An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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