197609987-10-21-2021-31-AS-ADUA-C7ZUX2-20211021155737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609987
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:57:47 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: 6	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Magda Minasyan, Administrator		TIME COMPLETED:	04:10 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 Analyst (LPA) Abeye Duguma met with the Administrator Magda Minasyan for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:10 PM and the following was noted: There is one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE storaged in the garage. The facility has four (04) bedrooms (all for residents) and three (03) bathroom of which one (01) is a half bath. The facility is currently occupying six (06) residents. The facility is fire cleared for six (06) non-ambulatory residents, six (06) ambulatory, zero (00) bedridden and hospice waiver for six (06). The backyard of the facility has outdoor furniture, with a covered shaded area for clients (umbrella was stored away due to high wind season). The facility does not have a body of water. The garage is currently being used as storage and laundry room. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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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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: 10/21/2021

NARRATIVE

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Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Living and dining room furniture were also checked. The living and dining room is neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke and carbon monoxide detectors are hardwired and interconnected and observed to be operational. Fire extinguishers are located in the kitchen, dining room and living/common room and observed to be full and last inspected on 08/27/2021. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 110.3°F. Towels and washcloths are not shared. There was enough clean linen available in stock located in the hallway cabinets. Medications: LPA observed medication cabinet to be locked and inaccessible to residents along with a complete first aid kit, located in the kitchen.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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