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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:17:49 PM

Document Has Been Signed on 08/28/2024 04:17 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/
DIRECTOR:		FERNANDEZ, MARIETTAFACILITY TYPE:
735
ADDRESS:1467 MEADOWLARK DRTELEPHONE:
(415) 939-4491
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Janne Angeles, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At approximately 12:50 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Janne Angeles, Designated Responsible Party (RP). Marietta Fernandez, Licensee was contacted and said to go ahead with the inspection without her. Facility is an Adult Residential Facility with four (4) ambulatory clients in care. LPA was informed that Client 1 (C1) and Client (C2) were away at Day Program and Client 3 (C3) and Client (C4) were present during today's visit. Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3) were present during todays inspection as well. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 1:10 PM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPA observed an activity schedule and was informed that each client has their own internet access device. Facility has internet available to clients in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced June 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted July 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated July 2024. LPA observed a supply of PPE, emergency supplies, multiple first aid kits, and flashlights for emergency preparedness. RP states the facility does not have a backup generator.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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: 08/28/2024
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Continued from LIC809...

At approximately 2:00 PM, LPA reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) client files reviewed have all the required paperwork. RP coordinates medical and dental visits for the clients and take them to their appointments.

At approximately 3:25 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. LPA reviewed P&I monies and logs, which were organized, maintained, and stored according to regulation.

RP informed LPA that the Licensee has appointed them as the new facility Administrator. LPA discussed the process and the documents that need to be submitted to CCL to make the change official with Licensing.

Required Change of Administrator Documents:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

No deficiencies cited during today's inspection. Exit interview conducted with RP whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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