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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804169
Report Date: 09/14/2023
Date Signed: 09/14/2023 11:35:21 AM

Document Has Been Signed on 09/14/2023 11:35 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:CASA FAIRVIEWFACILITY NUMBER:
216804169
ADMINISTRATOR:ELLIOT, ELISEFACILITY TYPE:
735
ADDRESS:138 HOLSTROM CIRCLETELEPHONE:
(415) 299-9100
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 2DATE:
09/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator/Licensee, Elise ElliotTIME COMPLETED:
11:45 AM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived announced to complete a Pre-Licensing Visit and met with Administrator/Applicant, Elise Elliot. Administrator/Applicant has applied for a Change of Location for an existing facility. Facility is an Adult Residential Home that provides care and assistance to Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Ambulatory Clients. Upon arrival, LPA was informed that there was 1 staff member on-site and that the facility's two clients were out of the community attending Day Program.

At approximately 9:30AM, LPA conducted a walk-though of the facility with Applicant/Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 2 client bedrooms, a staff bedroom/office, two bathrooms, and common areas. Facility has an infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Medications were observed to be locked in the facility's medication closet. Facility has required postings including the Community Care Licensing (CCL) Complaint Poster and Personal Rights for Individuals with Developmental Disabilities.

Facility's fire extinguisher was last inspected 07/6/2023. Facility's smoke detectors and carbon monoxide detectors were tested and operational. Facility's last fire drill was conducted August 2023.

At approximately 10:10AM, LPA reviewed staff files, client files, client medication records, and P&I monies. Staff and Client files were found to be well organized, thorough and contained the required documentation. Staff have current first Aid/CPR certifications. Client Medications were centrally stored and secure. P&I Monies were found to be documented, secure and not commingled.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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 2
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: CASA FAIRVIEW
FACILITY NUMBER: 216804169
VISIT DATE: 09/14/2023
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Continued from LIC809C

Component III has been waived due to Applicant/Administrator being a current Licensee.

No Deficiencies or Advisories given during visit.

Pre-Licensing completed. Facility is ready to be Licensed as an Adult Residential Facility.

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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