397005659-5-20-2021-27-AS-TWHE-C37UVQ-20210520155532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005659
Report Date: 05/20/2021
Date Signed: 05/20/2021 03:56:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	MEADOWLARK WAY CARE HOME		FACILITY NUMBER:	397005659
ADMINISTRATOR:	UMER QURESHI		FACILITY TYPE:	735
ADDRESS:	264 MEADOWLARK WAY		TELEPHONE:	(209) 224-1948
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	4	CENSUS: 4	DATE:	05/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Muhammad "Ali" Qureshi, Direct Suppiort Staff		TIME COMPLETED:	02:15 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	On 05/20/2021 at 8:53am, Licensing Program Analyst (LPA) T. White spoke with Licensee, Umer Qureshi regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 12:15pm, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Direct Support Staff, Muhammad "Ali" Qureshi and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 4 ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on October 29, 2020. Emergency Disaster Plan was last posted on 12/2020. Mitigation observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 05/01/2021. - LPA observed cleaning supplies(2 bottles of Clorox Spray, Lysol Spray Can, Hydro Peroxide) located in the garage accessible to clients in care. LPA observed 4 of 4 clients in the garage. Continued on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWLARK WAY CARE HOME	FACILITY NUMBER: 397005659
	VISIT DATE: 05/20/2021

NARRATIVE

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The following forms to be updated and submitted to CCLD by 05/28/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Direct Support Staff. Appeal rights and a copy of this report emailed.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWLARK WAY CARE HOME	FACILITY NUMBER: 397005659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 80087(g). LPA observed chemicals and cleaning supplies accessible to clients which poses an immediate health, safety risk to persons in care.
	POC Due Date: 05/20/2021
	Plan of Correction
1 2 3 4	Direct support staff removed chemicals and cleaning supplies from garage and locked it away. Direct support staff agreed to conduct an in-service training and submit proof to CCLD by 05/28/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

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