<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201156
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:28:17 PM


Document Has Been Signed on 06/02/2022 03:28 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR:VALERO, DESIREEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:270CENSUS: 202DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Desiree Valero, AdministratorTIME COMPLETED:
10:50 AM
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 6/2/22 at 8:35 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA explained reason for inspection and met with Administrator (ADM) Desiree Valero.

On 5/20/22, CCL received three Special Incident Reports (SIRs) from the ADM reporting a total of 11 residents and 1 staff that tested positive for COVID-19. Of the total 12 reported positive persons, 1 resident tested positive on 4/29/22, 1 staff tested positive on 5/6/22, 1 resident tested positive on 5/10/22, 1 resident tested positive on 5/12/22, 1 resident tested positive on 5/15/22, 4 residents tested positive on 5/16/22, and 3 residents tested positive on 5/17/22.

On 5/21/22, CCL received a SIR from the ADM reporting 2 residents and 1 staff that tested positive for COVID-19. All 3 identified positive persons were tested on 5/17/22.

LPA received a voicemail from S1 on 5/4/22 reporting the facility identified 2 positive persons. LPA returned S1's call the same day and left a voicemail advising the facility must submit a SIR to CCL as soon as possible. LPA did not receive the SIR for the identified positive persons reported on 5/4/22 by S1 until 5/20/22.
Deficiency is being cited based on LPA's record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Administrator Desiree Valero, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/02/2022 03:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: FAIRWINDS - WOODWARD PARK
FACILITY NUMBER: 107201156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2022
Section Cited

1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
CCL received a SIR on 5/20/22 reporting 12 positive persons. Of the total 12 reported positive persons, 1 resident tested positive on 4/29/22, 1 staff tested positive on 5/6/22, 1 resident tested positive on 5/10/22, and 1 resident tested positive on 5/12/22, which poses a potential health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2