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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880717
Report Date: 08/09/2021
Date Signed: 08/09/2021 03:33:50 PM

Document Has Been Signed on 08/09/2021 03:33 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FAIRHILL ELDER CAREFACILITY NUMBER:
331880717
ADMINISTRATOR:MANAHAN, GLYKA NICOLEFACILITY TYPE:
740
ADDRESS:31012 FAIRHILL CTTELEPHONE:
(951) 246-0597
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 5DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Barbara Balisi and Mercy Rapada, CaregiversTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Deborah Mullen and Jesse Gardner conducted an unannounced annual inspection. LPAs met with Barbara Balisi and Mercy Rapada, Caregivesr. LPAs conducted a walk through of the facility with Ms. Balisi. The facility is licensed for 6 residents (5 non-ambulatory and 1 bedridden). The facility has an approved hospice waiver for 4 residents. The facility is a two story home. Upstairs there are 4 bedrooms, 1 bath and a loft area. Downstairs there are 3 resident bedrooms, 2 baths, a living room, dining room and kitchen. The second story is not used by the residents.

LPAs conducted an inspection of the home and found that each resident bedroom was furnished with a bed, dresser and overhead lighting. 3 out of 3 resident's bedrooms did not have a night stand and a reading lamp for resident use. The bathrooms had handrails for resident safety. The facility had amble towels and linens for resident cleanliness. The kitchen had cups, plates, bowls, utensils, pots and pans. Sharp knives are kept in a locked drawer in the kitchen. The cleansers are kept in a locked cabinet under the kitchen sink. LPAs observed 7 days non-perishable and 2 days perishable food supply for residents.

LPAs observed the backyard to be fully fenced with a shade area for residents. During the inspection, LPAs observed dressers and drawers in the back yard along the fence, as well as on the patio. Facility staff was advised that the furniture needs to be removed from the backyard.

During the inspection, LPAs discussed infection control practices and procedures with Ms. Balisi and Ms. Rapada.

An exit interview was conducted and a copy of this report was reviewed with and provided to Ms. Balisi and Ms. Rapada.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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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Document Has Been Signed on 08/09/2021 03:33 PM - It Cannot Be Edited


Created By: Jesse Gardner On 08/09/2021 at 03:13 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAIRHILL ELDER CARE

FACILITY NUMBER: 331880717

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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On 8/9/2021 LPAs observed the combination kitchen/dining room area to be void of a smoke detector. Based on observation, the licensee did not comply with the section cited above in 1 out of 1 objects which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2021
Plan of Correction
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Licensee will install a smoke detector in the kitchen/dining room area and submit a picture documenting proof of correction to the Department by 8/10/2021.
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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2021


LIC809 (FAS) - (06/04)
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