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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002886
Report Date: 07/27/2023
Date Signed: 07/27/2023 09:57:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230718163630
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
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maria JalbunaTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Ombudsman Diane Stalder was present as well. House managers Sharon Pajarillaga and Mary Ann Kuvet arrived during the visit as well as Administrator Christine Wilkes.
During the course of the investigation, LPA interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as eviction notice. Regarding the allegation of unlawful eviction, the investigation revealed the following: On 06/30/2023, facility provided a thirty day eviction notice to Resident 1 (R1)'s family. Eviction notice noted that facility was unable to meet the resident's needs. Facility provided no documentation of the inability to meet the resident's needs nor the required department language for an eviction notice. On 07/26/2023, LPA received notice of rescinded eviction from Licensee. LPA provided a copy of eviction regulations to House Managers/ Licensee during the visit. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. CONTINUED ON LIC 9099C DATED 07/26/202.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20230718163630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
07/27/2023
Section Cited
CCR
87224(d)
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The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This req is not being met as evidenced by:
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Licensee provided a rescind notice to LPA/ family on 07/26/2023. Citation cleared.
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Based on record review, Licensee failed to ensure the facts for the reason for eviction was provided in the eviction notice. Eviction notice is missing specific facts as well as required department verbiage. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230718163630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2023
NARRATIVE
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The following citation is being cited per California Code of Regulations, (Title 22, Division 6, Chapter 8) on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report was provided as well as appeal rights.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3