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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004672
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:30:13 PM

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 ON CORNELLFACILITY NUMBER:
306004672
ADMINISTRATOR:CHRISTINE WILKESFACILITY TYPE:
740
ADDRESS:6112 CORNELL DRIVETELEPHONE:
(714) 248-9021
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:LVN Administrator, Rose EnriquezTIME COMPLETED:
12:45 PM
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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 and temperature checked by Staff and explained the reason for the visit.

During the visit LPA toured the facility with LVN Administrator Rose Enriquez. Facility is a 7 bedroom,( 6 resident bedrooms 1 staff bedroom) and 2 bathroom single story home. There are 6 Residents in care. 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 July 17, 2021. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and hand sanitizer. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV. Facility has smoke detectors and audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguisher which is fully charged. Facility has supply of PPE. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan located in binder readily accessible. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has a designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with LVN Administrator Rose Enriquez and 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: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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