<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610504
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:55:38 PM

Document Has Been Signed on 10/04/2024 01:55 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 4FACILITY NUMBER:
197610504
ADMINISTRATOR/
DIRECTOR:		CHENG, CHRISTINEFACILITY TYPE:
735
ADDRESS:19730 KITTRIDGE STREETTELEPHONE:
(818) 274-1809
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 3DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Christine Cheng-Administrator TIME VISIT/
INSPECTION COMPLETED:
02:00 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
On 10/4/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Christine Cheng. This is a Change of Ownership Application from facility #197610012 to #197610504 to operate an Adult Residential Facility (ARF). A Change in Ownership (CHOW) Application to operate an ARF was received by Community Care Licensing (CCL) on September 26th, 2023. A fire clearance was approved on February 9th, 2024, for six (6) Ambulatory clients for a total capacity of six (6). The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has two (2) fire extinguishers that were purchased on 8/23/2024 and are located in the common areas.

A tour of the physical plant was initiated at approximately 10:45am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) clients. Knives and other sharps were observed locked in the cabinet under the sink.

BEDROOMS: The facility has five (5) bedrooms, of which four (4) bedrooms are designated for clients' use and one (1) bedroom for staff use. All clients' bedrooms are furnished with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Additional linen is available in the closet located in the hallway.

BATHROOMS: The facility has two (2) bathrooms. Both bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids. The hot water delivered in the bathrooms measured at 11:00am to be at 109.8 degrees.

Continue On LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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 2
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 4
FACILITY NUMBER: 197610504
VISIT DATE: 10/04/2024
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
26
27
28
29
30
31
32
COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is no fireplace in the facility. The dining area has a dining room table to accommodate six (6) clients. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 11:15am to be 72 degrees.

GARAGE: The garage is used as extra storage for non-perishable, emergency food supplies and water. There is another freezer/refrigerator in the garage for additional food items.

LAUNDRY ROOM: The washer and dryer is located in a separate are next to the kitchen. Laundry chemicals are also kept in the laundry area which is always locked and under supervision.

MEDICATIONS: The medications are kept locked in a cabinet located in the office area which is next to the kitchen. At approximately 12:00pm to 1:00pm 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. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current.

Client Files: From 11am to 12pm LPA conducted a file review of all client records to ensure compliance of licensing forms. Clients’ files are complete and kept locked in the in the cabinet located in the office.
Staff Files: Staff files are also kept in a locked cabinet located in the office. From 1:00pm to 1:30pm LPA conducted staff file review, files were complete with all documents and training certificates.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) clients. There is no body of water.

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's physical environment 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: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2