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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610504
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:13:16 PM

Document Has Been Signed on 03/06/2025 01:13 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: 5DATE:
03/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Joseph Jose, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Huma Rahimi, Angela Panushkina, and Perchui Milena Khurshudyan met with the staff Rebecca Obadan, and the Licensee Joseph Jose was contacted by phone for a case management visit. The purpose of the case management visit is to address a deficiency observed during the course of complaint # 31-AS-20250214122033. The deficiency was not alleged but related to the complaint.

During the initial visit conducted on 02/24/2024, LPA reviewed the facility sketch and observed that initially the license was approved based on the sketch that was provided to Community Licensing Care Division (CCLD). However, during the initial visit conducted on 02/25/2025, LPA observed that staff room was converted to an extra client room and the office was converted to office/staff room. LPA conducted review of facility file and observed that the Licensee informed LPA Perchui Milena Khurshudyan about floor plan change back on 1/13/2025, the LPA Khurshudyan and/or Regional Office has not yet received the updated sketch approved by the fire inspector.

Therefore, based on interviews, LPA’s observation, and record reviews the facility will be cited and deficiency will be issued on LIC 809D.

Citation issued. Appeal rights explained

Copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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 01:13 PM - It Cannot Be Edited


Created By: Huma Rahimi On 03/06/2025 at 11:44 AM
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 4
FACILITY NUMBER: 197610504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2025
Section Cited
CCR
80022(b)(8)(A)

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(b) The plan and related materials shall contain the following: (8) A sketch of the grounds showing buildings,......... space used by the clients. (A) The sketch shall include the dimensions of all areas which will be used by the clients.
This requirement is not met as evidenced by:
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The Licensee agreed to submit an updated facility's sketch by the POC due date to LPA.
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Based on interviews and observation the Licensee altered the facility sketch without notifying the department which poses an immediate health and safety risks to clients 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:Huma Rahimi
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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