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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850066
Report Date: 01/07/2023
Date Signed: 01/07/2023 03:44:42 PM

Document Has Been Signed on 01/07/2023 03:44 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MEADOWGLADE, THEFACILITY NUMBER:
565850066
ADMINISTRATOR:ROXANA ESQUIVELPEREZFACILITY TYPE:
735
ADDRESS:6446 MEADOWGLADE DRTELEPHONE:
(805) 530-5301
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 6DATE:
01/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Sandra Zuniga TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit. At 2:13 p.m., the LPA spoke with staff and explained the reason for the visit. The Administrator was not available during the time of the visit and authorized staff, Sandra Zuniga to sign the report. This annual had a specific emphasis on infection control practices and procedures.

At 12:17 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.
COMMON SPACES: All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and recreational room furniture was observed to be in good condition. The LPA observed the fire extinguishers to be fully charged and last serviced on 02/16/2022. Signs are posted throughout facility to promote handwashing. At 2:59 p.m., fire/carbon monoxide detectors were tested and functioning properly. Medications and first aid kits are centrally stored and in a locked closet in the medication room. At 2:50 p.m., the LPA observed the back and front patio which has a covered outdoor area for client use. BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 2:46 p.m., the hot water in all the three (3) client restrooms measured between 124.3 and 126.4-degree Fahrenheit. At 2:55 p.m., the LPA spoke with the Administrator regarding the water temperature. The Administrator stated that the water temperature will be adjusted, and a water temperature log will be completed. 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. 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. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MEADOWGLADE, THE
FACILITY NUMBER: 565850066
VISIT DATE: 01/07/2023
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INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Today's report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2023 03:44 PM - It Cannot Be Edited


Created By: Emily Peraldi On 01/07/2023 at 03:04 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWGLADE, THE
FACILITY NUMBER: 565850066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 3 out of 3 client restrooms water temperature tested between 124.3 and 126.4 F which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2023
Plan of Correction
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The Administrator agreed to adjust the water temperature and ensure it reads between 105 -120 degrees F within 24 hours. The Administrator will provide documentation that they have adjusted the water heater temperature to CCL by 01/13/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2023


LIC809 (FAS) - (06/04)
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