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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:18:03 PM

Document Has Been Signed on 09/27/2022 03:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MEADOWLARK MANORFACILITY NUMBER:
486803841
ADMINISTRATOR:FERNANDEZ, MARIETTAFACILITY TYPE:
735
ADDRESS:1467 MEADOWLARK DRTELEPHONE:
(415) 939-4491
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Francis Fernandez, backup-AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Francis Fernandez, backup-Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA conducted a tour of the facility, all exits were unobstructed, medication was centrally stored, food supply per regulation, client P&I funds were not commingled. The facility has a screening station (hand sanitizer, thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). LPA was screened for COVID-19 symptoms and temperature was taken and documented. Staff and client's temperatures are taken and documented daily. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Facility staff have completed required training. N-95 respirator Fit testing for staff (Cal/OSHA requirement) is in process, Administrator purchased a test kit for staff . LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. LPA verified staff's vaccination status for COVID-19; staff have completed and have documentation in their files.

LPA requested the following updated forms to be submitted to Community Care Licensing by 10/27/2022:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · LIC 402 Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with back-up Administrator, whose signature on this document confirms receipt.
Due to issues with printer, this report was emailed to Administrator.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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