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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610504
Report Date: 10/23/2025
Date Signed: 10/23/2025 12:55:23 PM

Document Has Been Signed on 10/23/2025 12:55 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:		OSISANYA, ADEBAYO IGEFACILITY TYPE:
735
ADDRESS:19730 KITTRIDGE STREETTELEPHONE:
(818) 274-1809
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
10/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator -Tayo Labeodan TIME VISIT/
INSPECTION COMPLETED:
01:00 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 10/23/2025 an unannounced required annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan .Upon arrival, LPA met with the DSP / caregiver Trishana Farquharson-Thompson , who granted access to the facility. LPA explained the reason for the visit. Shortly after the Administrator, Tayo Labeodan arrived and helped with physical plant tour and staff/residents files.

During today's visit, at approximately 11:20am, LPA conducted a physical plant walk through to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.

The following was observed:

Facility is licensed for capacity of six (6) Level 2 - Ambulatory Clients. There are five (5) bedrooms in the facility of which four (4) bedrooms are designated for clients’ use, and one (1) for staff use only. There is an office area adjacent to kitchen. Bedrooms are appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility. LPA observed bathrooms have soap, paper towels and hand washing signs, and non-skid mats. The hot water temperature measured at 11:55 to be 107.2°F. Extra towels and linens were readily available. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Centrally stored medications are locked in the office, inside the white cabinets. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility works with two (2) shifts and has 1-2 staff for AM shift and 1 awake caregiver for PM shift.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: 10/23/2025
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
LPA observed the kitchen area; there was sufficient stock of one-week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored with expiration date labels on them. Food storage and preparation areas are clean and inaccessible to pests. LPA observed knives and sharp objects stored inside a locked kitchen cabinet inaccessible to clients in care. The kitchen has a working gas stove, microwave, and two (2) refrigerators. Extra emergency food was properly stored inside the pantry.

The common areas, which include dining and living room, appeared clean and were properly furnished. Temperature was comfortable, it was measured at 12:20pm to be 67°F. No obstructions and or tripping hazards throughout the facility were found.

The Facility has two (2) fire extinguishers, LPA observed they were last purchased on 4/9/2025. Laundry room is in the separate area next to the entrance. LPA observed all chemicals and detergents are kept locked inside the kitchen cabinet, are under supervision, and inaccessible to clients. Smoke detectors and carbon monoxide monitors were tested at 12:30pm and observed to be functional. LPA observed a clean covered patio and backyard furniture to accommodate six (6) clients. The backyard is properly fenced. Exit areas are free of obstructions and hazards, exit gates were unlocked and easily accessible. LPA checked the garage which is currently being used for storage and for facility maintenance purposes. LPA discussed the importance of maintaining care and supervision to meet the needs of residents. There is no body of water in the property.

Between 11:30pm to 1:00pm, LPA reviewed records and files of four (4) clients and three (3) staff/caregivers. A review of staff and resident records appeared to be complete. Residents' files contain signed admission agreements and a medical assessment, and all other required documentarians. A review of staff records indicates that all facility staff and those who required caregiver background checks have received criminal record clearances.

At approximately 12:35pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instructions are followed and checked for contamination. All medications are properly labeled and checked for expiration dates.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 10/23/2025
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
First-aid has all proper items and is current. New manual is also available.

Facility also provides planned activities for the clients.

An emergency exit plan/sketch is posted along the hallway with other posting requirements.

LPA collected LIC500, LIC9020.

Facility is in compliance with Title 22 Regulations at this time. No citations were issued during this visit.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4