306002886-9-9-2024-22-AS-MTEA-D8XQ5R-20240909115221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002886
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:52:46 AM

Document Has Been Signed on 09/09/2024 11:52 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
ORANGE COUNTY RO, 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:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:03 AM
MET WITH:	Ronald Wilkes		TIME COMPLETED:	12:06 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:03 AM, LPA Tea was greeted and granted entry into the facility by caregiver Maria Jalbuena and explained the reason for the visit. The administrator (AD) Ronald Wilkes arrived shortly to assist with the visit. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for four. Currently there are six residents, of which two residents are on hospice during today's visit.

Around 8:25 AM, LPA Tea reviewed six resident files and two staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in June 10, 2024. The administrator certificate expires on September 07, 2025.

LPA Tea along with AD Wilkes toured the facility at 9:17 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 6 resident bedrooms, 1 caregiver room, 3 bathrooms, living room, dining room, kitchen and a garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 113.1 F degrees and 113.3 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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 I	FACILITY NUMBER: 306002886
	VISIT DATE: 09/09/2024

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LPA observed sharps locked in the dishwasher after being used in the morning, normally they are locked in the storage closet where medication and files are stored. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. The fire extinguisher was fully charged in the dining area. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There is one exit gate that is self-latching and operational on the left side of the house. LPA observed PPE supplies, emergency food and water stored in storage closet by the front entry way. Facility provides activities based on their personal choice. Residents walk around the neighborhood and facility grounds. Musician comes plays during special occasions such as birthdays. There is a fitness instructor that comes weekly to do chair exercises and dancing. Occasionally students would bring their pets for pet therapy for residents to play with. The residents also color and play games and puzzles. At the time of the visit, LPA observed residents watching game shows on television.

LPA reviewed medication storage and administration. Medications are stored in a locked storage closet by the front entryway. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Ronald Wilkes and a copy of this report LIC809, along with the 809-C, LIC858, LIC858-C, LIC859, and LIC9102TV were read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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