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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606097
Report Date: 11/30/2021
Date Signed: 11/30/2021 02:33:04 PM

Document Has Been Signed on 11/30/2021 02:33 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAIRHAVEN HOME IIIFACILITY NUMBER:
197606097
ADMINISTRATOR:ZENAIDA T VIRIFACILITY TYPE:
735
ADDRESS:22743 HAMLIN ST.TELEPHONE:
(818) 992-0116
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Gracela C. MortelTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Eleza Jackson conducted an unannounced annual inspection using the Annual Inspection Tool. A physical tour was conducted at 1:15pm and the following was observed:

Infection control: Upon arrival, Caretaker Plablo invited LPA Jackson inside, However, he did not follow Covid protocols; he did not check LPA Jackson’s temperature nor was there any sign-in visitors’ log apparent. Proper signage was observed inside of the facility. Administrator stated they have sufficient PPE supplies for residents and staff.

Smoke detectors/carbon monoxide were deemed to be in operating condition. Fire extinguisher is up to code.

Resident rooms: All residents bedrooms were properly furnished with appropriate bedding, sufficient lighting, and the room appeared to be clean.

Bathrooms: LPA Jackson observed appropriate hand washing signs posted in the bathroom.

Laundry service: LPA Jackson observed that the cleaning products/chemicals are inaccessible to residents.



Medications are centrally stored and locked.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients.
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All deficiencies cited on LIC 809 D. Appeal Rights explained, Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Eleza Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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Document Has Been Signed on 11/30/2021 02:33 PM - It Cannot Be Edited


Created By: Eleza Jackson On 11/30/2021 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRHAVEN HOME III
FACILITY NUMBER: 197606097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
POC Due Date: 12/03/2021
Plan of Correction
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Administrator shall have in-service with facility staff on the importance of checking all visitors temperatures. Copy of in-service sign in sheet shall be sent to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Eleza Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
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