197609987-6-15-2020-31-AS-SDIZ-BQLSGS-20200615135226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609987
Report Date: 06/10/2020
Date Signed: 06/15/2020 01:53:02 PM

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:	FAIRWEATHER SENIOR FACILITY		FACILITY NUMBER:	197609987
ADMINISTRATOR:	MINASYAN, MAGDA		FACILITY TYPE:	740
ADDRESS:	19343 FAIRWEATHER ST.		TELEPHONE:	(818) 917-1097
CITY:	CANYON COUNTRY	STATE: CA	ZIP CODE:	91351
CAPACITY:	6	CENSUS: 5	DATE:	06/10/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Magda Minasyan		TIME COMPLETED:	03:00 PM

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	Licensing Program Analysts (LPA's) Sandra Diaz and Rosaura Valenzuela conducted an announced Pre-Licensing visit to this facility for a Change of Ownership and met with applicant Magda Minasyan, Administrator. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime" with applicant. Fire Clearance dated 03/16/20 was received for three (3) non-ambulatory residents, three (3) ambulatory, of which none (0) may be bedridden. The facility currently has five (5) non ambulatory. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a four (4) bedroom, single story home. Today's site visit consisted of LPA virtually touring the physical plant inside and outside, review of files, observation of medications. The fire extinguishers are located in the one (1) in the kitchen and two (2) in the common areas. The facility has single smoke detectors, and combination smoke detectors with the carbon monoxide detectors located throughout the home. The hot water was tested in the common bathroom and measured at a 106.7. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are two (2) shared bedrooms, and two (2) private bedrooms. There is no staff bedroom, staff will be awake staff 24/7 shifts. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in the kitchen area. Medications are stored in a designated secured cabinet in the kitchen. The first aid kit is readily available. There are two (2) bathrooms in the facility. The bathrooms have appropriate grab bars installed. (continued to LIC 809-C)

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Sandra Diaz	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRWEATHER SENIOR FACILITY	FACILITY NUMBER: 197609987
	VISIT DATE: 06/10/2020

NARRATIVE

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(continued from LIC 809)

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the garage by the washer and dryer. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility indoors appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.
The backyard side area of the home and garage are full with collection of items that clutter both the side and garage which need to be cleared out.

There is a sitting area in the front yard for residents and a portable gazebo will be put up for residents to conduct outdoor activities in the backyard area. The backyard is fenced. The garage has an entrance through the kitchen and on the side of the facility. There is no body of water in the facility.

The following are need for correction and the Centralized Application Bureau (CAB) will be notified. Upon receipt of correction by applicant, LPA Diaz will notify the CAB Analyst who will then inform the licensee when the license has been approved.

1^st aid Manual,
Clear the side of the house and garage
Medication Lock box for refrigerator medications
Send a list which will identify the location and type of detector, (smoke, carbon monoxide or combo) in the facility as they are different throughout the facility.
New LIC 200 with facility sketch regarding non ambulatory residents ( there are five (5) non ambulatory in care). Exit interview conducted and copy of this report issued

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Sandra Diaz	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020

LIC809 (FAS) - (06/04)

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