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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610513
Report Date: 06/04/2025
Date Signed: 06/04/2025 05:01:42 PM

Document Has Been Signed on 06/04/2025 05:01 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 3FACILITY NUMBER:
197610513
ADMINISTRATOR/
DIRECTOR:		MORTEL, GRACELAFACILITY TYPE:
735
ADDRESS:22743 HAMLIN STREETTELEPHONE:
(818) 274-1809
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Laila KulungaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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At approximately 12:50 p.m. on 06/04/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 04/22/24 for an annual visit. It 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.

At 1:15 p.m. LPA reviewed client and personnel files. All files were complete and available for audit. At approximately 1:45 p.m., LPA observed Special Incident Reports (SIRs) involving Client #1 (C1) and Client #2 (C2) from 03/01/25 and 04/03/25 which were not sent to Community Care Licensing (CCL). This deficiency is cited on the LIC 809-D page.

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

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

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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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)
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Document Has Been Signed on 06/04/2025 05:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 06/04/2025 at 04:26 PM
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 3
FACILITY NUMBER: 197610513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above in not sending at least tow (02) incident reports which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee will submit all incident reports which were not sent to CCL by the POC due date.
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above in not following the Emergency Disaster Plan during the power outage on 05/30/25 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee to review and modify the emergency disaster plan and submit revision to CCL by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


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: 06/04/2025
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Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The living room contained board games, puzzles, art supplies, and furniture in good condition. At approximately 2:15 p.m., the house telephone was called and deemed functional. At 2:30 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. A linen closet in the hallway contained an adequate supply of fresh sheets and towels. Another closet nearby contained hygiene supplies.

At 3:05 p.m. LPA tested the carbon monoxide and smoke detectors in the office to be functional. 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 exercise equipment and furniture which was shaded and in good repair. Two (02) out of two (02) emergency exit paths were free of hazards and unlocked. 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 3:15 p.m. LPA measured the water temperature in the bathroom near the dining area to be 116.1 degrees Fahrenheit. At 10:55 a.m. LPA observed a fully charged fire extinguisher hung near the office area. It was purchased on 10/20/2023.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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