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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610503
Report Date: 03/06/2025
Date Signed: 03/06/2025 02:51:41 PM

Document Has Been Signed on 03/06/2025 02:51 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:
03/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Joseph Jose, Licensee TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 3/6/2025 at approximately 1:45pm, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan, Angela Panushkina and Huma Rahimi conducted a Case Management visit in conjunction to subsequent complaint visit Control# 31-AS-20250219094156. LPAs met with the Licensee and explained the reason for the visit.

During the initial complaint visit made on 02/24/2025, LPA observed that facility floor plan changed by converting the patio into two private bedrooms. LPA also observed that one (1) of the rooms was occupied by client 1 ( C1), and the second bedroom was vacant. LPA conducted an interview with the facility Administrator who stated that there is no final sketch available to provide to CCLD. Although, the Licensee/Executive Director informed LPA about floor plan change back on 1/13/2025, the LPA and/or Regional Office has not yet received the updated sketch, approved by the Fire inspector.

Deficiency issued on LIC809-D.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 03/06/2025 02:51 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 03/06/2025 at 12:12 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 2
FACILITY NUMBER: 197610503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
80086(b)

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Alterations to Existing Building or New Facilities (b)The licensing agency shall have the authority to require that the licensee have a building inspection by a local building inspector if the agency suspects that a hazard to the clients' health and safety exists. This requirement is not met as evidence by:

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The licensee should submit a new/updated facility sketch along with LIC200 to LPA by POC date.
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Based on interviews, observation, document review and inspection, the licensee did not comply with the section cited above by not providing the updated facility sketch of new construction to a facility, to CCLD. This poses a potential health and safety risk to residents in care.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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