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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004672
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:47:06 PM


Document Has Been Signed on 06/20/2022 01:47 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
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:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House Manager, Sharon Pajarillaga, Administrator Sarah WilkesTIME COMPLETED:
02:00 PM
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 and temperature checked by Staff . LPA explained the reason for the visit.

During the visit LPA toured the facility with House Manager Sharon Pajarillaga. Administrator Sarah Wilkes arrived during visit. 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 a sign in, sanitization and temperature check station. Visitor check in sheet is located at entrance. 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, paper towels and wipes. Restrooms have 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 a months 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 secure location for hazardous toxins. 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. 6 of 6 files were reviewed. Clients emergency contact information and Physicians reports are current. Facility has a designated visitation area with ample shading.

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: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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