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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803056
Report Date: 03/01/2022
Date Signed: 03/02/2022 10:42:42 AM

Document Has Been Signed on 03/02/2022 10:42 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRWAY HOMEFACILITY NUMBER:
216803056
ADMINISTRATOR:ALBERO, JOEFACILITY TYPE:
735
ADDRESS:2001 MILL ROADTELEPHONE:
(415) 895-1567
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sophia Albarico - staffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Sophia Albarico who contacted administrator. Administrator Joe Albero wasn't able to come for this visit. Clients were present at the facility. There are activities planned for clients during the day if they want to participate since day program is closed at this time.

LPA arrived at the facility and had her temperature checked to be logged into notebook. During facility tour on 3/1/2022 with administrator Wilson Benoit facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 04/2021 at the time of the visit. Carbon monoxide detector and Smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet under the kitchen sink. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. However, LPA observed and learned that facility has a folding bed in clients’ room (see picture) for staff to sleep. Client C1 has a history of seizures. Department reviewed records and wasn’t able to find and doctor’s notes regarding plan for client’s seizure supervision. Per Title 22 Regulations facility is not allowed to have a staff sleeping in the same accommodations as a client. (see documentation, pic, confidential name list, LIC 809-D) Facility hot water temperature in clients' bathroom faucet measured between 111.5 degrees F and 112.6 degrees F in 2 out of 2 faucet within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted monthly with the last one being conducted on 2/10/2022.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056
VISIT DATE: 03/01/2022
NARRATIVE
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility, container with hand sanitizer and other items designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has PPE supply stored by kitchen area. There has been new staff hired and clients since COVID-19. Clients’ medications are stored and locked in medication cabinet between kitchen and family room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and facility is working towards acquiring N-95 fit testing.

Based upon review of records, statements by the administrator, and observation, LPA learned that a staff S1 who started working at the facility on 9/2021 and individual I1 staying at the facility are not fingerprint cleared and/or associated to the facility. (see copies, LIC 809-D, civil penalty)

Immediate Civil Penalties are being assessed in the amount of $600.00 due to individuals not being finger printed cleared and associated to the facility.

*****Total Civil Penalties issued today in the amount of $600.00

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056
VISIT DATE: 03/01/2022
NARRATIVE
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Department is requesting Licensee to update the following documents and submit to CCL by 3/8/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 03/02/2022 10:42 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/01/2022 at 02:41 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 individuals which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that 2 individuals in the facility were not associated - 1 staff S1 and I1 individual who is staying in the facility. LPA spoke w/adm who confirmed no association and or fingerprint clearance for either. (see LIC 812 + documentation)
POC Due Date: 03/02/2022
Plan of Correction
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Facility administrator agress to submit an LIC 9098 self certification that all individuals, working, residing and/or volunteering in this facility have been fingerprint cleared and associated to the facility. In addition, administrator to submit an updated LIC 500 with all staff on schedule.
LIC 9098 and LIC 500 to be submitted to CCLD by POC date of 3/2/2022. (civil penalty)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2022 10:42 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/01/2022 at 02:41 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,the licensee did not comply with the section cited above in 1 out of 1 bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.LPA observed a bedroom for 2 clients with 2 beds which has a third bed that per staff and administrator is being used by staff to sleep overnight due to client's seizures.
POC Due Date: 03/15/2022
Plan of Correction
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Facility administrator agrees to ensure that all client's needs will be meet and personal rights will be respected. Facility to acquire and submit updated complete LIC 602, doctor's orders for need of client's supervision overnight due to seizures, and plan on how facility will meet the needs of the client during the night with the understand that staff might not sleep in the room.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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