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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601674
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:49:59 PM

Document Has Been Signed on 10/26/2021 02:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAIRGREEN HOUSEFACILITY NUMBER:
198601674
ADMINISTRATOR:GEORGE LOPEZFACILITY TYPE:
735
ADDRESS:2051 FAIRGREEN AVETELEPHONE:
(626) 443-1313
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator: Genny GuadalquivirTIME COMPLETED:
03:00 PM
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On 10/26/21 at 1:00 PM, Licensing Program Analysts (LPA) Nune Margaryan arrived at this facility unannounced to conduct an annual inspection visit. Upon arrival, LPA met with Administrator Genny Guadalquivir who assisted with the visit. The purpose of visit was explained. The facility is licensed to serve four (4) clients, ages 18 through 59 years old. The facility is approved for three (3) Ambulatory and one (1) Non-Ambulatory clients. Currently, there are four (4) clients at the facility.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. LPA toured the physical plant areas inside and outside to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

LPA and Staff toured the facility at 1: 40PM and the following were observed:


All indoor and outdoor passageways are free of obstruction. Facility has a total of four (4) client bedrooms and two (2) bathrooms, living room, kitchen, dining area, and indoor/outdoor activity areas.
Client rooms were sanitary and had furnished appropriately. The bathrooms were observed to be clean and operational. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The facility has central air and heating accommodations. There are sufficient lightings in all rooms to ensure comfort and safety for clients. There is a functioning telephone on the premises and there is emergency lighting, such as flashlights and night lights.
The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins and knives are in a secured cabinet and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged.
Continued 809C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674
VISIT DATE: 10/26/2021
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The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The washer and dryer are located outside by the garage area. There is a detached two car garage with additional storage of food supply. The garage door is always kept locked and inaccessible to clients.

Per California Code of Regulations, Title 22, deficiencies were not observed during the visit. Exit interview conducted and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
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