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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880717
Report Date: 06/19/2024
Date Signed: 06/19/2024 09:30:52 AM

Document Has Been Signed on 06/19/2024 09:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FAIRHILL ELDER CAREFACILITY NUMBER:
331880717
ADMINISTRATOR/
DIRECTOR:		MANAHAN, GLYKA NICOLEFACILITY TYPE:
740
ADDRESS:31012 FAIRHILL CTTELEPHONE:
(951) 246-0597
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 5DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver, Barbara BalisiTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On 6/19/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual visit. LPA met with Caregiver, Barbara Balisi who was informed of the purpose of the visit. During today's visit, there was five (5) residents and two (2) staff present.

LPA conducted a tour of the facility with Caregiver Balisi. During the tour, LPA observed the facility is made up of a two-story home providing three (3) resident rooms, two (2) bathrooms along with a kitchen dining room, living room and attached garage. Outside shaded seating area is available for the residents. Indoor and outdoor passageways are free of obstruction. Caregiver Balisi tested one of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the home. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for 2-day perishables and 7-day non-perishable food items. Medications are secured in a locked hallway closet. LPA reviewed the Medication Administration Record for two (2) residents along with their physical medications and did not discover any discrepancies. Cleaning solutions and disinfectants are secured in the locked garage. LPA observed emergency water and food supply stored in the garage. LPA reviewed random resident files. Resident files reviewed had signed admission agreements and LPA noted residents with a Dementia diagnosis had updated physician's reports.

During today's visit, LPA did not issue any deficiencies. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Balisi.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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