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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:16:13 PM

Document Has Been Signed on 08/10/2023 01:16 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
SANTA ROSA RO, 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:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Jannie Angeles, training AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Carol Fowler conducted a Required-1 Year inspection, on 08/10/2023 at approximately 9:25am, and met with Administrator in training, Jannie Angeles. LPA observed 3 caregivers on duty during the inspection.

Currently four (4) clients in care. Facility has an approved fire clearance for four (4) ambulatory clients. All client rooms are private. The facility has a required infection control plan. The facility has a required emergency disaster plan.

Facility had an evacuation fire drill on 06/20/2023, including staff & clients. Clients, 1 out of 4, special diets regarding food are followed per staff interviews, and per LPA's observations during the inspection.

The LPA reviewed four (4) staff files. Administrator certificate for Ashley Fernandez is current-#6027553735, expires 09/15/2023 Administrator in training Jannie Angeles certificate is pending #6067325735. All staff have required criminal record clearance. All staff have required training. The LPA reviewed three (3) client files. Client files were complete. Resident P&I monies were maintained as required, and not mixed with facility funds/any other funds.

LPA toured the facility with the Administrator in training. All exits were unobstructed. The facility's one (1) fire extinguisher was serviced and tagged as required on 06/20/2023. Facility had three (3) smoke alarms, and all were working properly when checked during the inspection. Facility has two (2) carbon monoxide detectors that were working properly when checked during the inspection. Facility had a first aid kit stored in the locked medication closet and one in the client transportation vehicle. The facility had a sufficient supply of perishable and nonperishable food.

Continue on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MEADOWLARK MANOR
FACILITY NUMBER: 486803841
VISIT DATE: 08/10/2023
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Continued from LIC809


LPA requested the following forms be submitted by 8/17/23:

Personnel Report
Designation of Responsibility
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan

There are no deficiencies cited today. Exit interview conducted with the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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