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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001951
Report Date: 12/05/2023
Date Signed: 12/05/2023 10:19:44 AM

Document Has Been Signed on 12/05/2023 10:19 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:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Cindy HallTIME COMPLETED:
10:30 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
At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced Annual Required inspection at this facility and met with Administrator Cindy Hall. At approximately 8:30AM, LPA reviewed 4 of 4 Client records and 2 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid certification was current in staff files reviewed. Facility does not handle P&I money. Administrator's Certificate was current with an expiration date of 04/12/2024.
At approximately 9:30AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. Disaster Drills are conducted monthly.


No deficiencies were observed in the areas inspected. No citations issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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 1