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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850066
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:32:47 PM

Document Has Been Signed on 02/09/2022 02:32 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,
, CA
FACILITY NAME:MEADOWGLADE, THEFACILITY NUMBER:
565850066
ADMINISTRATOR:JOAN CARTWRIGHTFACILITY TYPE:
735
ADDRESS:6446 MEADOWGLADE DRTELEPHONE:
(805) 530-5301
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 4DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Roxana EsquivelTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:51 AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Program Director/Administrator Roxana Esquivel. Entrance interview conducted.

The LPA, along with facility Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room, recreation room, and therapy room furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was observed to be adequately screened.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility laundry area was observed. All chemicals, including laundry detergent, are stored in a locked closet.

3 (three) facility fire extinguishers were noted to be charged, but last annual service was performed on 06/04/2020.

KITCHEN: The facility does not contain a full kitchen, only a kitchenette. The kitchenette consists of pantry and dry food storage area, refrigerator and freezer. As such, the facility does not contain 7-day supply of perishable and 2-day supply of non-perishable foods. Program Director indicated facility food for lunch and dinner is stored and prepared off-site. Breakfast is prepared in the kitchenette and snacks are available throughout the day for clients.

Report Continued on LIC 809-C

SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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 02/09/2022 02:32 PM - It Cannot Be Edited


Created By: Kelly Dulek On 02/09/2022 at 01:34 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
,
, CA

FACILITY NAME: MEADOWGLADE, THE
FACILITY NUMBER: 565850066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to the Administrator/Program Director has been acting as Administrator for the facility since 11/01/2021, but does not have an initial Administrator certificate issued, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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LPA verified the Administrator Certificate is pending as of 12/23/2021. Program Director agreed to contact the Administrator Certification section to inquire when the Certificate will be issued. In the interim, Program Director will contact corporate to see if someone with a valid certificate can act in their place.
Type A
Section Cited
CCR
80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in all 3 of total Fire Extinguishers were last serviced on 06/04/2020, not annually which poses an immediate health risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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Program Director agreed to schedule the fire extinguishers to be serviced as soon as possible. Program Director will send proof of completed annual service by 02/11/2022.
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:
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022


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
CCLD Regional Office,
, CA
FACILITY NAME: MEADOWGLADE, THE
FACILITY NUMBER: 565850066
VISIT DATE: 02/09/2022
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BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 3 (three) total bedrooms, all of which are designated as shared client bedrooms.

RESTROOMS: The LPA observed 3 restrooms in the facility; all of which are designated for client use. Client restrooms are clean and sanitary and in operating condition with non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Program Director/Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks, however clients are not consistently encouraged to wear face coverings in common areas. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

During the facility visit, it was also noted there had been a change of Administrator effective 11/01/2021. The current Administrator’s initial Administrator Certificate showed as pending, received in the Administrator Certification section on 12/23/2021.



The following recommendations were made:
- N95 fit testing for all staff
-Post PINs and review with staff and clients
-Post handwashing, cough/sneeze etiquette, physical distancing reminder signs

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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