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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002886
Report Date: 07/27/2023
Date Signed: 07/27/2023 09:57:42 AM


Document Has Been Signed on 07/27/2023 09:57 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MEADOWLARK GARDENS IFACILITY NUMBER:
306002886
ADMINISTRATOR:CHRISTINE WILKESFACILITY TYPE:
740
ADDRESS:5912 MIDIRON CIRCLETELEPHONE:
(714) 840-1776
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92649
CAPACITY:6CENSUS: 6DATE:
07/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Maria Jalbuna and Christine WilkesTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20230718163630. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the investigation for complaint #22-AS-20230718163630, LPA observed facility did not submit a copy of the eviction notice for Resident 1 to Licensing as required.









Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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Document Has Been Signed on 07/27/2023 09:57 AM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MEADOWLARK GARDENS I
FACILITY NUMBER: 306002886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
87224(f)

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A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement has not been met as evidenced by:
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Licensee to review regulation and provide a statement of understanding to LPA by POC due date.
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Based on record review, Licensee failed to ensure a copy of the eviction notice for Resident 1 was submitted to Licensing within 5 days of issuance. This poses a potential health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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