486803841-8-3-2026-21-AS-SSTN-DWLTJQ-20260803144642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803841
Report Date: 08/03/2026
Date Signed: 08/03/2026 02:46:58 PM

Document Has Been Signed on 08/03/2026 02:46 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 MANOR		FACILITY NUMBER:	486803841
ADMINISTRATOR/ DIRECTOR:	ANGELES, JANNE		FACILITY TYPE:	735
ADDRESS:	1467 MEADOWLARK DR		TELEPHONE:	(415) 939-4491
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 4	DATE:	08/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Administrator Janne Angeles		TIME VISIT/ INSPECTION COMPLETED:	02:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 09:35 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by Lead Caregiver Joanne Sigua who has Designation of Facility Responsibility (RP). Administrator Janne Angeles was called to advised of today's required inspection and Admin arrived at approximately 10:00 AM to further assist with today's inspection. Facility is an Adult Residential Facility (ARF) with license for four (4) ambulatory clients. LPA was informed that 1 client was present and 3 were away in day programming. Facility is vendorized with North Bay Regional Center (NBRC). At approximately 10:05 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature,clean without odors, 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. 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. In addition, LPA observed an air purifier, piano, games, small fish aquarium and comfortable and clean seating for clients in care. Continued on LIC809-C

Bethany Moellers
Star Stevenson
	DATE: 08/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/03/2026

NARRATIVE

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Continued from LIC809

Facility's fire extinguisher was observed charged and was last serviced June 2026. Smoke and Carbon Monoxide detectors were tested and operational during inspection LPA observed a supply of PPE, emergency supplies, multiple first aid kits, and flashlights for emergency preparedness.

At approximately 12:30 PM LPA reviewed five (5) staff files and four (4) client files. Five (5) of 5 staff files reviewed have the required paperwork and proof of current First Aid, CPR training, and TB clearance. Four (4) of four (4) client files reviewed have all the required paperwork. Client C1 who was away at day programming during inspection is noted on 2023 IPP to be "ambulatory" while a Physican's assessment from 2026 indicates C1 to be "Non-ambulatory" and a Technical Violation of CCR 80020(a) for facility not maintaining their Fire Clearance is issued. Facility is advised to have C1 re-evaluated by their MD or to request a fire clearance to care for at least one (1) non-ambulatory client.

Facility coordinates medical and dental visits for the clients and takes them to their appointments.

At approximately 12:45 PM LPA reviewed P&I monies and logs, which were organized, maintained, and stored according to regulation.

At approximately 12:50 PM LPA observed Medicines to be centrally stored and secure and the Medication Administrator Record to be accurate.

LPA obtained copies of the following documents during today's inspection.
LIC500 (personnel record)
LIC 610D (updated disaster plan)

Technical Violation is cited from the California Code of Regulations (CCRs). Failure to correct the Technical Violation may result in a future civil penalty assessment.

This report was reviewed with Administrator Janne Angleles and Appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026

LIC809 (FAS) - (06/04)

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