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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:18:08 PM


Document Has Been Signed on 06/14/2022 01:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COOL MEADOW CAREFACILITY NUMBER:
331880585
ADMINISTRATOR:MA SATCHEL LECITAFACILITY TYPE:
740
ADDRESS:29787 COOL MEADOW DRTELEPHONE:
(951) 246-0214
CITY:MENIFEESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 6DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Licensee- Long ZhangTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA met with Corporate Board Member Long Zhang, who was informed of the purpose of the visit. At the time of visit there was 3 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and a single entry point was designated where symptoms screenings and temperature checks occur daily. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all 2 restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

LPA observed staff member S1 at the facility, but was not on the facility roster. LPA verified staff members background clearance with the department but noted that the staff had not been transferred. LPA will issue civil penalties for this in the amount of $500 and will document this on an 809-D page.

Deficiencies were noted on LIC 809-D page and cleared on the day of the visit. An exit interview was conducted, and a copy of this report along with technical advisory notes, 809-D pages and appeal rights were reviewed and provided to facility corporate board member, Long Zhang.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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 9


Document Has Been Signed on 06/14/2022 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COOL MEADOW CARE
FACILITY NUMBER: 331880585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with powedered bleach that was found under the sink of a residents shared bathroom. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Staff was able to remove the powedered bleach right away and place it in a located cabinet under the sink of the kitchen and the deficency was cleared by the end of the visit.
Type B
Section Cited
CCR
87309(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with centrally stored medications that were left unlocked. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Licensee was able to place the lock back on the cabinet where the medication was being kept.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 06/14/2022 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COOL MEADOW CARE
FACILITY NUMBER: 331880585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with staff member S1 that was not transferred to the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee will send in employee transfer to the department and send LPA a written statement stating that this has been completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9