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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004331
Report Date: 05/27/2022
Date Signed: 05/27/2022 09:41:06 AM


Document Has Been Signed on 05/27/2022 09:41 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 VIIFACILITY NUMBER:
306004331
ADMINISTRATOR:CHRISTINE AND RON WILKESFACILITY TYPE:
740
ADDRESS:9401 NAUTILUS DRIVETELEPHONE:
(714) 840-1776
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:House Manager, Sharon Pajarillaga and Administrator Ron WilkesTIME COMPLETED:
09:50 AM
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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 staff and explained the reason for the visit.

During the visit LPA toured the facility with Caregiver. Facility is a 7 bedroom,( 6 resident bedrooms 1 staff bedroom), 2 Full bathrooms and 6 half bathrooms single story home. There are 6 Residents in care. During visit House Manager Sharon Pajarillaga and Administrator Ron Wilkes arrived at facility. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 11/5/2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing eating in Kitchen and relaxing in bedrooms. Facility has smoke detectors and audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguisher which is fully charged. Facility has ample supply of PPE. Facility has 2 refrigerators and pantry 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 clients. LPA reviewed Residents files during visit. LPA observed 6 of 6 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 Administrator and House Manager. 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)
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