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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:09:39 PM

Document Has Been Signed on 12/05/2022 04:09 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:
12/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Francis Fernandez, back-up administratorTIME COMPLETED:
04:18 PM
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Licensing Program Analyst (LPA) Karina Canela arrived at Meadowlark Manor Facility on 12/05/2022 for the purpose of conducting a case management - incident inspection. LPA met with back-up administrator Francis Fernandez.
Meadowlark Manor self-reported an incident involving client (C1) and former staff (S1) to Community Care Licensing (CCL) via an incident report on 11/22/2022. The incident occurred on 11/17/2022 per the report submitted by the facility and staff immediately took action the following day (once it was reported to them). LPA conducted interviews, reviewed staff files and obtained copies. LPA will review documents received and return to issue citations if warranted.

No deficiencies issued during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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