<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002888
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:35:57 AM


Document Has Been Signed on 05/27/2022 11:35 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 IIIFACILITY NUMBER:
306002888
ADMINISTRATOR:CHRISTINE WILKESFACILITY TYPE:
740
ADDRESS:6102 CORNELL DRIVETELEPHONE:
(714) 840-1776
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:House Manager, Sharon Pajarillaga, Administrators Ron Wilkes and Sarah WilkesTIME COMPLETED:
11:45 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) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by House Manager Sharon Pajarillaga and explained the reason for the visit.

During the visit LPA toured the facility with House Manager. Facility is a 7 bedroom,(6 resident bedrooms 1 staff bedroom) and 2 bathrooms single story home. There are 6 Residents in care. During visit Administrators Ron Wilkes and Sarah Wilkes arrived at facility. LPA observed proper covid signage at front entrance of facility as well as a sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 9/7/2023 and 11/5/2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained working was basin, soap, toilet paper, and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV and relaxing in bedrooms. Facility has operating smoke detectors, carbon monoxide detector and audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguisher which is fully charged. Facility has 30 day supply of PPE. Facility has refrigerator with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. LPA observed 6 of 6 resident files. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with House Manager and Administrators. A copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1