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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803056
Report Date: 03/17/2023
Date Signed: 03/17/2023 01:56:20 PM

Document Has Been Signed on 03/17/2023 01:56 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, 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:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Diana Cardenas, Lead StaffTIME COMPLETED:
02:00 PM
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On 3/17/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and met with Lead Staff, Diana Cardenas. Administrator, Joe Albero was contacted and arrived later in the visit. The facility currently provides care for 6 clients, 5 of which were present at the time of visit and 1 of which was attending day program.

LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the living room and staff quarters were found to be last charged on 2/21/2023 at the time of the visit. Smoke detectors in client bedrooms and throughout were inspected and found to be in working order. Carbon monoxide detectors were also tested and found to be fully functional. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted file review for 6 out of 6 staff and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinets located in the staff quarters, garage and under the kitchen sink and all found to be secured. There was a supply of hygiene products and paper products available and kept in each client's respective bedrooms or provided to clients will full staff support. Facility provides direct assistance with hand washing for clients supplying paper towels and soap dispensers each use. All client bedrooms have lighting & appropriate furnishings with some bedrooms modified for limited furnishings due to some client behaviors. Water was measured at faucets used by clients and was measured between 110.1 to 111.0 degrees F which is within regulation.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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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: 03/17/2023
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Medications and facility records are stored in designated cabinets located in the staff office and found to be secured. Clients were observed to be interacting with staff in the backyard and in the living room area. Clients were seen watching television, participating in puzzles and socializing with staff, all of which appeared to be comfortable.
LPA conducted a medication check and review with Lead Staff who demonstrated appropriate medication intake, recording and administration procedures. A full file review was conducted on client records and found documents to be well organized and up to date. LPA found that client (R1's) Individual Service Plan from 2022-2023 is not on record. Licensee will be following up with R1's Case Manager for record request or updating. LPA observed a large fallen tree located in the backyard. Administrator is in the process of cutting and removing the tree to prevent potential incidents.

Administrator, Joe Albero's Administrator Certification 6001876735 is currently active until 5/2/2023.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 3/24/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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