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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804169
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:57:43 PM

Document Has Been Signed on 09/20/2024 03:57 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:CASA FAIRVIEWFACILITY NUMBER:
216804169
ADMINISTRATOR/
DIRECTOR:		ELLIOT, ELISEFACILITY TYPE:
735
ADDRESS:138 HOLSTROM CIRCLETELEPHONE:
(415) 299-9100
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 2DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Administrator Elise ElliotTIME VISIT/
INSPECTION COMPLETED:
04:13 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Elise Elliot. Facility contact information was reviewed.

At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Food waste disposed of in open garbage can without a lid. LPA noticed a pervasive and prominent odor of food waste in the home and observed garbage can containing food waste to not be covered with flies present and buzzing around the garbage can. Admin explained they compost here and the food waste is emptied out a couple of times per day. LPA advised of regulation 80088(f)(1) which states that all containers used for storage of solid waste must have a tight fitting cover. LPA and Admin discussed getting bins that are made specifically for composting that contain filters in their attached lids to mitigate odor and flies. Cleaning supplies and toxin storage cabinet was locked. Sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 109.5 degrees F in the kitchen, and 105.3 degrees F and 105.1 degrees F in the respective bathrooms, all which are within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/2/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 8/3/2024.

At approximately 2:30pm LPA conducted a review of two [2] resident records and one [1] staff record. LPA discussed with Admin the requirements pertaining to Appraisal Needs and Services Plans.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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 6
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: CASA FAIRVIEW
FACILITY NUMBER: 216804169
VISIT DATE: 09/20/2024
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Continued from 809...

At approximately 3:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. No deficiencies.

Elise Elliot Administrator Certificate 7034442735 expires 3/26/2025. All fees are current as of this time.



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
LIC400- Cash Affidavit
Surety Bond

No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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