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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803056
Report Date: 03/18/2025
Date Signed: 03/18/2025 01:31:58 PM

Document Has Been Signed on 03/18/2025 01:31 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:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Administrator, Joe AlberoTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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03/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 clients in care. LPA was greeted by staff. Administrator arrived later during visit.

At approximately 9:55 am, LPA and Staff toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

3 out of 4 rooms were furnished per regulation. LPA observed one client (C1) room to not have a bed. Per conversation with staff, client is destructive and had just broke their bed (Deficiency Cited). Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 110.6 and 115.4 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were just purchased 03/2025. Facility has a pull fire alarm that was last inspected 05/29/2024. Facility has a gated/locked pool that is inaccessible to clients. Toxins, sharps and other items that could pose threat if available to clients were located in the garage and under the kitchen sink and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P & I monies were documented.


continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRWAY HOME
FACILITY NUMBER: 216803056
VISIT DATE: 03/18/2025
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LPA conducted a review of 4 client records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. Facility conducts monthly fire and disaster drills with the last one being conducted 2/20/2025.


.Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC402- Surety Bond

See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 01:31 PM - It Cannot Be Edited


Created By: Anthony Loera On 03/18/2025 at 12:56 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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Staff observation, the licensee did not comply with the section cited above in that C1 bedroom # 4 did not have a bed present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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Administrator to submit proof to CCL of purchased bed for C1 by POC due date 03/26/2025.
Section Cited
Deficient Practice Statement
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4
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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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