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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601059
Report Date: 11/12/2023
Date Signed: 11/12/2023 02:20:08 PM


Document Has Been Signed on 11/12/2023 02:20 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MEADOW GARDENS OF MENLO PARKFACILITY NUMBER:
415601059
ADMINISTRATOR:JOAN JOHNSONFACILITY TYPE:
740
ADDRESS:800 ROBLE AVENUETELEPHONE:
(650) 322-4100
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:45CENSUS: 24DATE:
11/12/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Resident Care Director Ed DewittTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Jason Lund arrived unannounced to conduct an Post-Licensing and Annual/Required inspection. LPA met with Resident Care Director Ed Dewitt and explained the reason for the visit. Census:24

LPA Lund & Resident Care Director Ed Dewitt toured/inspected the facility inside and outside. The facility is approved/ has locked perimeter fence and gates. LPA toured the kitchen and inspected two (2)- day supply of perishable and seven (7)- day supply of non-perishable foods. Residents’ bedrooms were toured, furniture, beddings were observed, and bathrooms have paper towels, and grab bars. Hot water temperature measured at 109 - 120 degrees Fahrenheit - 1 in residents’ bathrooms.

First-aid kit is inspected and complete. Facility temperature was maintained at 71 degrees Fahrenheit. Last Fire drill was conducted on 9/23/23 which staff/residents practice once a month. Fire extinguisher was fully charged and last inspected on 8/15/23. Dual Smoke & Carbon monoxide detectors were operational. LPA reviewed five (5) residents and Three (3) staff files. Staff had criminal record clearances to work and are associated to the facility.

No deficiencies cited today. Exit interview and report left.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2023
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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