306004652-2-10-2025-22-AS-EKIM-D6VQ3F-20240705114842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004652
Report Date: 07/05/2024
Date Signed: 02/10/2025 08:18:05 AM

Document Has Been Signed on 02/10/2025 08:18 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:	OAK MEADOW ASSISTED LIVING		FACILITY NUMBER:	306004652
ADMINISTRATOR/ DIRECTOR:	NICOLAE GAVRILAS		FACILITY TYPE:	740
ADDRESS:	5642 OAK MEADOW DRIVE		TELEPHONE:	(714) 728-5934
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	07/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Nicolae Gavrilas		TIME VISIT/ INSPECTION COMPLETED:	12:05 PM

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On July 5, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Nicoloae Gavrias and explained the purpose of the visit.

The facility is licensed to operate for four (4) non-ambulatory of which one (1) may be bedridden and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident bedrooms, two (2) bathrooms, living room, dining area, kitchen, attached 2-car garage, and an outside covered patio area.`

LPA Kim toured indoor and outdoor of the physical plant with AD Nicolae Gavrilas. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, and Resident Room 3. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 112.8 degrees Fahrenheit in bathroom 1 and 115.5 degrees Fahrenheit in bathroom 2. A comfortable temperature of 76 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and smoke/carbon monoxide detectors were operable. A working telephone (714-777-7030) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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: OAK MEADOW ASSISTED LIVING	FACILITY NUMBER: 306004652
	VISIT DATE: 07/05/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA conducted an audit of resident files (R1-R3) and medication and medication administration review that were all in order and complete. LPA Kim conducted 2 resident interviews and 2 staff interviews.

A Technical violations was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report were provided to Administrator Nicolae Gavrilas.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC809 (FAS) - (06/04)

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