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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850066
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:49:52 PM

Document Has Been Signed on 02/17/2022 03:49 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:JOAN CARTWRIGHTFACILITY TYPE:
735
ADDRESS:6446 MEADOWGLADE DRTELEPHONE:
(805) 530-5301
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Roxana EsquivelTIME COMPLETED:
03:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management - Incident visit at the facility today. The LPA met with Program Director Roxana Esquivel.

The purpose of today's visit was to review records and obtain pertinent copies of facility records pertaining to a self reported incident of sexual abuse that was reported to Community Care Licensing (CCL) on 2/16/22 for client #1 (C1).

During today's visit LPA toured the facility with the Program Director, reviewed C1 and staff #1 (S1) records and obtained copies of pertinent documents. Interview with Program Director starting at 12:24 pm revealed that C2 spoke with staff #2 (S2) on 2/9/22 not 2/16/22 as noted on the incident report received on 2/16/22. Program Director completed a revised incident report during the facility visit and submitted it to CCL by email. Program Director stated that S1 was terminated on 2/11/22.

During facility tour with Program Director at 11:54 am LPA observed that S2 is not associated to the facility. S2 stated that they started working at the facility on 1/4/22. During interview with Program Director LPA was advised that they notified their Regional Manager Jessica Galindo on 2/9/22 regarding the past due annual fees however, they did not receive a response from them. During a review of C1's records starting at 2:05 pm LPA observed that the facility does not have a medical assessment, TB test or needs and services plan on file for C1.

Further investigation is needed regarding the alleged sexual abuse. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and was accepted on 02/17/2022. The investigation is assigned to Investigator Dennis Douglas.

Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 02/17/2022 03:49 PM - It Cannot Be Edited


Created By: Joann Rosales On 02/17/2022 at 01:45 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
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Program Director had S2 leave the facility during the facility visit and will not return until they are associated to the facility. Program Director stated that they will ensure all staff are fingerprint cleared and associated prior to working in this facility, per regulations.
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Based on interview and record review, the licensee did not comply with the section cited above as S2 is working and not associated to the facility which poses an immediate safety risk to persons in care.
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Type B
02/21/2022
Section Cited
CCR80036(a)

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80036(a) LICENSING FEES(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.




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Program Director stated that they will provide documentation of payment of past due annual fees totaling $681.00 to CCL by 2/21/22.

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Based on interview and record review, the licensee did not comply with the section cited above as the annual fees are past due which poses a potential personal rights risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2022 03:49 PM - It Cannot Be Edited


Created By: Joann Rosales On 02/17/2022 at 03:19 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited
CCR
85068.2(b)

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85068.2 Needs and Services Plan(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include

This requirement is not met as evidenced by:
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Program Director stated that they will provide documentation of C1's Needs and Services Plan to CCL by 2/25/22.
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Based on interview and record review, the licensee did not comply with the section cited above as C1 does not have a Needs and Services Plan on file which poses a health and safety risk to persons in care.
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Type B
02/25/2022
Section Cited
CCR80069(b)

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80069 Client Medical Assessment (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met evidenced by:
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Program Director stated that they will provide documentation of C1's Medical Asessment and TB test to CCL by 2/25/22.
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Based on interview and record review, the licensee did not comply with the section cited above as C1 does not have a Medical Assessment on file which poses a health and safety risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MEADOWGLADE, THE
FACILITY NUMBER: 565850066
VISIT DATE: 02/17/2022
NARRATIVE
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Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Today's reports, civil penalty and appeal rights were reviewed and issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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