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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004331
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:55:16 PM


Document Has Been Signed on 06/18/2024 03:55 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 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: 5DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator Ron WilkesTIME COMPLETED:
04:15 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 staff 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 two (2) Hospice residents present during today’s visit.

This is a single story with attached garage facility. The facility has seven bedrooms (six resident rooms and one staff room) and eight bathrooms.

At around 2:10PM, LPA conducted a tour of the physical plant accompanied by Caregiver and House Manager. 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. Bathrooms were operational with water temperature measured between 110.4 to 114.2 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, toxins 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 fridge were operational. Facility has supply of emergency food and water. Facility has one fire extinguisher which was fully 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 MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (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 VII
FACILITY NUMBER: 306004331
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 and sanitizing stations upon entrance and in common areas. 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 11/20/2023. 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 three residents (R1-R3) 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 MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (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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