197610513-4-22-2024-31-AS-NRED-D4KP4D-20240422105858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610513
Report Date: 04/22/2024
Date Signed: 04/22/2024 10:59:26 AM

Document Has Been Signed on 04/22/2024 10:59 AM - 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 3		FACILITY NUMBER:	197610513
ADMINISTRATOR/ DIRECTOR:	MORTEL, GRACELA		FACILITY TYPE:	735
ADDRESS:	22743 HAMLIN STREET		TELEPHONE:	(818) 274-1809
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 6	DATE:	04/22/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Joseph Jose and Tolu Jose		TIME VISIT/ INSPECTION COMPLETED:	11:10 AM

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At 8:45 a.m. on 04/22/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted a prelicensing visit. 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 III (197606097). Fairhaven Home III was last visited on 12/29/2022 for an annual visit. The facility is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 ambulatory residents.

LPA conducted a record review of client files at 9:00 a.m. All required documents were available for review.

LPA and the applicant toured the facility inside and out at 10:00 a.m.

LPA observed a maintained front yard. Postings were present in the office area for the facility sketch, confidential complaint contacts, facility license, emergency disaster plan, grievance procedure, personal rights, house rules, COVID precautions, and activity schedule. A screening station near the living room contained a digital thermometer, visitor log, hand sanitizer, N95 masks, surgical masks, and gloves.

The facility has seven (07) private bedrooms. Bedroom #7 was locked and served as a staff room. All bedrooms were tidy and contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The living room contained board games and furniture in good condition. A client was observed watching television. At 10:05 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. A linen closet in the hallway contained an adequate supply of fresh sheets and towels. Another closet nearby contained hygiene supplies.

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)

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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 3	FACILITY NUMBER: 197610513
	VISIT DATE: 04/22/2024

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At 10:15 a.m. LPA tested the carbon monoxide detector in the office to be functional. The house phone was available near the dining room table. LPA called the house phone at 10:20 a.m. and deemed it to be operational. Medications, confidential files, and a first aid kit were locked in the office. Sharps and cleaners were locked below the sink. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and in the garage. The stove hood was clean and surfaces were sanitary. Two laundry machines in good repair were located just past the kitchen. Detergents were locked above the appliances.

The outside areas contained furniture which was shaded and in good repair. Workout equipment was also available. Two (02) out of two (02) emergency exit paths were free of hazards and unlocked. One (01) out of two (02) exits used a self-closing, inward-facing latch. The garage was locked and contained client belongings, additional PPE, clothing, and an extra refrigerator and freezer.

The facility has three (03) bathrooms. All bathrooms contained liquid soap, paper towels, and a trash can with a tight fitting lid. At 10:45 a.m. LPA measured the water temperature in the bathroom near the dining area to be 112.3 degrees Fahrenheit.

At 10:50 a.m. LPA tested the dual function smoke and carbon monoxide detector near the main entrance to be operational. At 10:55 a.m. LPA observed a fully charged fire extinguisher hung near the office area. It was purchased on 10/20/2023. At 11:00 a.m. LPA observed a fully-stocked first aid kit.

During today's inspection, the facility is in compliance with Title 22 regulations. 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)

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