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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 07/07/2022
Date Signed: 07/07/2022 05:20:13 PM

Document Has Been Signed on 07/07/2022 05:20 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, 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:
07/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Marie Fernandez, AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced for the purpose of delivering findings on complaint #21-AS-20220316111542.

Upon arrival, LPA observed 2 of 3 Meadowlark Manor staff (S1 & S2) without face masks as required. S1 was observed not wearing a mask and preparing client's lunch. S1 was also observed not wearing a face mask as required on 03/21/2022 during previous visit. LPA reminded staff they are required to wear face masks in the facility regardless of their vaccination status.
Additionally, during visit, LPA observed clients sitting near a fan. LPA observed the facility internal thermostat to be 81 degrees F (pictures taken) while it is 85 degrees F outside of the facility. LPA reminded staff that the facility must be at a comfortable temperature for clients and S1 turned on the air conditioning.



Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Marie Fernandez, Administrator whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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Document Has Been Signed on 07/07/2022 05:20 PM - It Cannot Be Edited


Created By: Karina Canela On 07/07/2022 at 04:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MEADOWLARK MANOR
FACILITY NUMBER: 486803841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2022
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties: (a)The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by: Based on:
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Administrator to review CCL PINs regarding current COVID requirements. Administrator to train all staff regarding the COVID face mask requirement. Include date, time, duration, subject, attendees, and signatures & submit to CCL by POC due date.
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On 7/7/2022, Administrator failed to protect the personal rights of clients in care to receive safe & healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care,in that Staff (S1&S2) failed to wear face covering while providing care & supervision to clients in care...
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(continued...) which is in violation of official government orders requiring staff to wear face coverings while working under specified conditions. This is a potential personal rights, health & safety risk to clients in care.
Deficiency Dismissed
Type B
07/25/2022
Section Cited
CCR80088(a)

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80088 Furniture, Fixtures, Equipment, and Supplies: (a) A comfortable temperature for clients shall be maintained at all areas.
This requirement was not met as evidenced by:
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Administrator to submit their plan of how they will ensure the regulation 80088(a) to CCL by POC due date 7/25/2022
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Based on observation and statements, Administrator did not ensure the above regulation due to the internal facility temperature reading at 81 degrees F while it is 85 degrees outside. This is a potential health and personal rights risk to clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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