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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603531
Report Date: 05/05/2022
Date Signed: 05/09/2022 02:21:52 PM

Document Has Been Signed on 05/09/2022 02:21 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:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR:ALMERO, CARMENFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.,TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14CENSUS: 9DATE:
05/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator / Carmen Almero
Licensee Representative / May Cabrera		TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Joe Katrdzhyan and Yating Yang conducted an announced pre-licensing visit. LPAs met with Administrator / Carmen Almero and Licensee Representative / May Cabrera for the purpose of conducting a pre-licensing inspection. Licensee / Fairoaks Guest Homes, Inc. has submitted an application to operate an Adult Residential Facility for a capacity of fourteen (14) residents, ages 18 through 59. The facility has an approved fire clearance for twelve (12) ambulatory clients and two (2) non-ambulatory clients. Fire clearance was granted on 11/1/21. The new application is being processed as a change of facility type. There are currently nine (9) clients living at the home.

LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The home is located in a residential neighborhood. The home consists of two floors, a ground floor and the main floor. ONLY the main floor will be licensed through Department of Social Services. The ground floor is inaccessible from the main floor and will only occupy live-in staff. Clients will have NO access to the ground floor rooms. The ground floor has separate entrances/exits. A tour of the main floor includes seven (7) bedrooms, four (4) bathrooms, a living room, dining room, kitchen, office, staff room, patio and indoor/outdoor activity areas. The bathroom located inside the office is only used by staff. The garage is located on the ground floor and is being used for storage purposes. The garage is kept locked and inaccessible to clients.

LPAs observed a fully equipped living room and a dining room with sufficient dining capacity. Client bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Client bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each client. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPAs observed an appropriate food supply of two days of perishables and seven (7) days of non-perishables. LPAs observed a pull-switch fire alarm in the
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
VISIT DATE: 05/05/2022
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hallway, near the bathroom. The home is equipped with a centralized sprinkler system. The home has a central heating system and individual AC units inside each client bedroom.

Medications and First Aid Kit will be centrally stored and locked in the kitchen cabinet, located near the kitchen/dining room area. First aid kit is fully stocked with a manual. Client and staff records are centrally stored and locked in the cabinets located in the office. Clients P&I moneys are also centrally stored and locked in the cabinets located in the office. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to clients. Cleaning supplies and dishwashing soap are stored underneath the kitchen sink making it inaccessible to residents. No firearms will be kept at the facility. The facility smoke/carbon monoxide detectors were tested and operable throughout the facility. LPA observed the fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The washer and dryer are located on the ground floor, inside the storage room/laundry room. All toxins such as cleaning solutions and detergent soap are also kept in the storage room/laundry room. The storage room/laundry room is kept locked and inaccessible to clients at all times. There is no pool or other bodies of water.

LPA observed the Emergency Disaster Plan, Personal Rights and Facility Sketch posted inside the facility as mandated by Title 22 Regulations.

The following concern was observed during today's visit;
  • LPA observed four (4) clients are over the age of 60. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.


Prior to licensure, the Licensee shall submit an Exception request for clients over the age of 60 in accordance with Title 22 Regulations Section 85068.4 / Acceptance and Retention Limitations.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
VISIT DATE: 05/05/2022
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During todays' visit, LPA reminded the Administrator that prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

Component III was conducted during this visit.
LPA used the inspection tool and the pre-licensing checklist for an Adult Residential Facility during this visit.
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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