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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610503
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:23:09 PM

Document Has Been Signed on 10/10/2024 02:23 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAIRHAVEN HOME 2FACILITY NUMBER:
197610503
ADMINISTRATOR/
DIRECTOR:		CHENG, CHRISTINEFACILITY TYPE:
735
ADDRESS:21036 CHASE STREETTELEPHONE:
(818) 274-1809
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rosemarie Santos-CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 10/10/2024 at approximately 9:45am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a subsequent Pre-Licensing Inspection and met with the Staff/Caregiver Rosemarie Santos. LPA explained the reason for the visit. Facility Administrator Christine Cheng arrived shortly after.
This is a Change of Ownership Application from facility #197605213 to #197610503 to operate an Adult Residential Facility Level 2. An Application to operate an Adult Residential Facility (ARF) was received on 09/25/2023 by Community Care Licensing (CCL). A fire clearance was approved on February 9th, 2024 for six (6) ambulatory clients, for a total capacity of six.

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. Facility is a single story home. Today's site visit consisted of LPA touring the physical plant at 10:30am inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, gas stove and sink. The Facility has two (2) other frizer/refrigerators located in the patio and garage. There is an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). An emergency supply of water was also observed in the kitchen and patio areas. Sharps, knives and kitchen chemicals were observed locked in a kitchen drawer.

BEDROOMS: There are five (5) bedrooms of which four (4) bedrooms are designated for clients' use, and one (1) is for staff. Bedroom #1 is currently occupied by two (2) clients, bedrooms #2, #3, #4 are private. All four (4) clients' rooms were furnished with beds, night stand, chairs, dresser, bedding and linen. All bedrooms have sufficient lighting and closet space. LPA toured and observed bedrooms to be clean and appropriately furnished. There are sufficient supplies of linen and towels in the linen cabinet.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRHAVEN HOME 2
FACILITY NUMBER: 197610503
VISIT DATE: 10/10/2024
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BATHROOMS: The facility has two (2) bathrooms, of which one (1) is designated for clients' use and the other one is for staff use. LPA observed bathrooms to have the proper fixtures, grab bars, non-skid mats, and no cleaning supplies were observed accessible in the bathrooms. The hot water delivered in the bathrooms measured at 1:00pm to be 118 degrees F.

COMMON AREAS: Facility has a living room/activity area. It was equipped with living room furniture, a television, and a coffee table. There is a fireplace which is non-operational. The dining area is located next to the kitchen, dining table observed to accommodate six (6) clients. Furniture was observed to be comfortable and in good condition. The smoke alarms and carbon monoxide detector are dual. Detectors are hard wired and inter-connected, they were tested at 11:15am to be operational. The fire extinguisher is located in the kitchen area and was last purchased on 10/10/2024. The facility has comfortable temperature of 76 F. Complete First Aid with the new manual is located in the kitchen.



OFFICE/STAFF WORKSTATION: Office and storage area is located next to the living room. Desk, office chair and filing cabinet was observed. Staff and clients' files were observed locked in the filing cabinet. Clients' medication is also kept centrally stored in the locked cabinet.

LAUNDRY ROOM: The laundry room is located in the garage. Cleaning supplies were stored away and inaccessible to the clients.

GARAGE: Garage is currently being used as a storage. LPA observed Laundry machines, emergency food supply and holiday decorations nicely organized inside plastic boxes.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) clients. The facility backyard is fenced and has sufficient yard space. No bodies of water was observed.

FILES/ MEDICATION REVIEW: LPA reviewed Clients and Staff files between 11:15am to 1:00pm. Files were complete with all required documents and training certificates. LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRHAVEN HOME 2
FACILITY NUMBER: 197610503
VISIT DATE: 10/10/2024
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In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, CA Code of Regulations, the facility appears to be compliant and ready for licensure. CAB will be advised.

Exit interview conducted and copy of this report signed and delivered to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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