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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600361
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:54:55 PM


Document Has Been Signed on 12/28/2023 01:54 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:FAIRBANKS HOME CAREFACILITY NUMBER:
015600361
ADMINISTRATOR:DRUGA, GHEORGHEFACILITY TYPE:
740
ADDRESS:2940 SOMERSET AVENUETELEPHONE:
(510) 889-1948
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 4DATE:
12/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Druga Gheorghe, AdminstratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) K. Nguyen returned to facility today to continue the Annual Required Inspection that was initiated on 12/21/23.

LPA toured facility with Gheorghe including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 4 bedrooms are occupied by residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/28/2023. First aid kit was observed to be complete.

LPA reviewed 4 residents records. LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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