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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803056
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:14:56 PM

Document Has Been Signed on 05/16/2024 02:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRWAY HOMEFACILITY NUMBER:
216803056
ADMINISTRATOR/
DIRECTOR:		ALBERO, JOEFACILITY TYPE:
735
ADDRESS:2001 MILL ROADTELEPHONE:
(415) 895-1567
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Aniceto AguirreTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 09:15 AM to conduct an Annual Required inspection and was greeted by Staff. LPAs and staff discussed the purpose of the visit. Administrator Jose Albero was contacted but did not attend the visit. The facility currently provides care for 6 clients.

LPA and Staff initiated a tour of the facility around 9:30 AM and made the following observations: Facility was found to be at a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 119 and 120 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available in a secured closet.

Cabinet containing cleaning supplies were stored with sharps and LPAs advised Staff to separate them. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Underneath the kitchen sink, LPAs observed moisture with discoloration on a disposable white pad due to a leak in the sink. The yard was observed to have debris and animal feces on the sidewalk.

Medications were centrally stored and locked. Emergency food and water is stored in the Pantry and the garage. Personal Protective Equipment is stored in the cabinet.


Continued on LIC809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056
VISIT DATE: 05/16/2024
NARRATIVE
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Continued from LIC809

Fire extinguishers were last serviced 02/21/23. Facility has a pull fire alarm that sends notification to the fire department. Facility agrees to service all fire safety equipment. Facility has a carbon monoxide detector located in the facility which was missing a battery and once replaced, it indicated the battery was low. Most recent fire/disaster drill was conducted 04/20/2024.

Client cash resources were reviewed. LPA conducted file reviews for five staff and five clients. 3 out of the 5 staff did not have current First Aid/CPR certification. 4 out of the 5 clients did not have their updated IPP/ISP in their files. Medications and medication records were reviewed. Administrator Certificate for Administrator, Jose Albero 6001876735 exp 05/22/2025.

Exit interview conducted. Copy of report discussed and provided to Lead Staff. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 06/16/2024:

LIC 500 Personnel Report
LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/16/2024 02:14 PM - It Cannot Be Edited


Created By: Helena Rummonds On 05/16/2024 at 01:22 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: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 which sharps were stored with cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Staff immediately removed the cleaning supplies from underneath the sink and secured them in the secured laundry 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/16/2024 02:14 PM - It Cannot Be Edited


Created By: Helena Rummonds On 05/16/2024 at 01:22 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: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having debris in the yard, animal feces on the backyard sidewalk, massage chair with a missing cushion, moisture and discoloration underneath the sink due to the crack and leak of the sink, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
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Administrator agrees to repair the sink, remove the massage chair, clean the backyard of all the debris and submit photos of the repairs to the LPA by POC due date of 6/16/2024.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having 3 out of the 5 staff with updated First AId and CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administrator agrees to audit staff records and identify all staff who need updated First Aid and CPR certification and submit updated certificates to LPA by POC due date of 06/06/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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