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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601674
Report Date: 05/25/2023
Date Signed: 05/25/2023 03:36:48 PM

Document Has Been Signed on 05/25/2023 03:36 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:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator- Genny GuadalquivirTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff Maria Ramos and Katherine Valdez and shortly after met with Administrator Genny Guadalquivir was later joined by the Health and Services Coordinator Elsa Montes who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for Three (3) Ambulatory and One (1) Non-Ambulatory Clients. Currently, there are four (4) clients in placement. During today's visit, LPA used the CARE Inspection Tool to complete the Required - 1 Year inspection.

Physical plant was toured with Maria Ramos. The facility is located in a residential area. A tour of the single-story facility includes: Four (4) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, indoor/outdoor activity areas and a detached garage. The bathrooms are clean and operational, grab bars and non-skid mats in place. Clients bedrooms were checked, furniture, closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility and measured within Title 22 regulations. 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. Extra food and emergency food/ supplies kept in locked garage.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and was fully charged and serviced. A shaded area with is provided in the back yard. The backyard is free of debris/hazards and passageways are free of obstructions. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. There is a functioning telephone on the premises.

Continuation on 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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