306002888-6-18-2024-22-AS-JTIE-D6CR3Y-20240618124043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002888
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:40:50 PM

Document Has Been Signed on 06/18/2024 12:40 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 III		FACILITY NUMBER:	306002888
ADMINISTRATOR:	CHRISTINE WILKES		FACILITY TYPE:	740
ADDRESS:	6102 CORNELL DRIVE		TELEPHONE:	(714) 840-1776
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 6	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator Ron Wilkes		TIME COMPLETED:	12:50 PM

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On 6/18/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by House Manager and granted entry after stating the purpose of the visit. Administrator Ron Wilkes was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for four (4) residents. Currently, there are zero (0) Hospice residents present during today’s visit.

This is a single story with detached two-car garage facility. The facility has seven bedrooms (six resident rooms and one staff room) and two bathrooms.

At around 9:15AM, LPA conducted a tour of the physical plant accompanied by House Manager and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 107.0-116.6 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. LPA observed kitchen stove, microwave and toaster oven were operational. A fire extinguisher was charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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 III	FACILITY NUMBER: 306002888
	VISIT DATE: 06/18/2024

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE).

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 11/16/2023. The facility has operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 7/11/2023- 7/11/2024. The facility is current on Community Care Licensing annual dues.

A review of six residents (R1-R6) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Christine Wilkes # 6005396740 - Expiration 07/16/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator Wilkes, and a copy of the report was provided.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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