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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610505
Report Date: 04/22/2024
Date Signed: 04/22/2024 02:15:28 PM

Document Has Been Signed on 04/22/2024 02:15 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAIRHAVEN HOME 1FACILITY NUMBER:
197610505
ADMINISTRATOR/
DIRECTOR:		MORTEL, GRACELAFACILITY TYPE:
735
ADDRESS:20601 KITTRIDGE STREETTELEPHONE:
(818) 274-1809
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
04/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Tolu JoseTIME VISIT/
INSPECTION COMPLETED:
02:15 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
At 11:20 a.m. on 04/22/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted a prelicensing inspection. LPA met with the applicant and current staff and disclosed the reason for the visit.

Today’s prelicensing visit is conducted due to a change of ownership with clients in care. The previous facility was Fairhaven Home I (197605835). Fairhaven Home I was last visited on 07/20/2023 for an annual visit. The facility is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 ambulatory residents.

LPA and applicant toured the facility inside and out at 11:25 a.m.

An unlocked gate surrounded the perimeter of the facility. The front yard was well maintained and included shaded patio furniture in good repair. A non-slip mat was placed at the main entrance.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:30 a.m. LPA measured the room temperature to be 69 degrees Fahrenheit. The living room contained a television, reading material, and furniture in good condition. LPA observed postings in the office area for the facility license, personal rights, confidential complaint contacts, emergency disaster plan, neighborhood complaint procedure, grievance procedure, COVID precautions, and facility sketch. A small wash room near the office area contained locked, inaccessible medications.

At 11:35 a.m. LPA observed two (02) fully-charged fire extinguishers in the kitchen. They were purchased on 10/20/2023 and 06/20/2023. The kitchen surfaces were sanitary and the stove hood was clean. Adequate supplies of perishable, non-perishable, and emergency food were observed in the refrigerator, freezer, pantry, and garage. Sharps and cleaners were locked below the sink.

A laundry area was observed near the kitchen. It contained a washing machine and dryer. Both were in working order. Detergents were locked above the appliances.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAIRHAVEN HOME 1
FACILITY NUMBER: 197610505
VISIT DATE: 04/22/2024
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
The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. Two (02) client bedrooms were private and one (01) was shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, and a non-skid mat in the shower. At approximately 11:45 a.m. LPA measured the water temperature to be 106.1 degrees Fahrenheit.

At approximately 11:55 a.m. smoke and carbon monoxide detectors were tested and operational. At 12:00 p.m. LPA observed a fully-stocked first aid kit. The house telephone was called and deemed operational at 12:10 p.m.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked with self-closing latches. The garage was locked and contained old files, extra supplies, an extra refrigerator and freezer, and emergency food and water supplies.

LPA conducted a record review of client and personnel files at 12:20 p.m. All required documents were available for review.

During today's inspection, the facility was in compliance with Title 22 regulations.. No immediate health and safety risks were observed. Prelicensing is complete and this facility has no deficiencies

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2