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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001951
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:08:31 AM

Document Has Been Signed on 01/31/2023 11:08 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRWAY ADULT RESIDENTIALFACILITY NUMBER:
125001951
ADMINISTRATOR:HALL, BEATRICEFACILITY TYPE:
735
ADDRESS:3905 F STREETTELEPHONE:
(707) 798-2309
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 6CENSUS: 4DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cindy HallTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Administrator Cindy Hall.

Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Facility posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer. Facility has PPE supplies.

There were no deficiencies found in the areas inspected.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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