361881241-12-15-2023-56-AS-ACON-CYJQWT-20231215113229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881241
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:32:45 AM

Document Has Been Signed on 12/15/2023 11:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	FAIRVIEW LIVING LLC		FACILITY NUMBER:	361881241
ADMINISTRATOR:	ABDALLATEF, AHMAD		FACILITY TYPE:	740
ADDRESS:	1089 W HUFF STREET		TELEPHONE:	(909) 805-5025
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	10	CENSUS: 6	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Lupe, Caregiver		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts, Amber Coleman, (LPA Coleman) Bianca Wolcott, (LPA Wolcott) arrived at the Fairview Living, LLC Facility unannounced to conduct an Annual Inspections. LPA's introduced selves and stated purpose of the visit. LPA were greeted by Staff Member, Lupe Leon; who granted entry, asked to sign in and provided a space to work. Administrator, Najeh Hamed was notified of LPA's visit via telephone. Staff Member, Lupe accompanied LPAs on a walk through of the facility and provided resident records for review. The facility has 5 resident bedrooms, 1 staff room, 2 bathrooms, kitchen, dining area, living room, attached garage, and backyard. The facility is approved for 10 residents. 2 non-ambulatory, 10 ambulatory and hospice waiver for 2. Staff reported there are 6 residents in care . The census at the time of the visit was 2. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: Pathways were observed to be free of obstruction. The facility was maintained in comfortable temperature. LPA inspected resident bedrooms and found that each room included required furniture such as: mattresses, night stands, adequate storage and sufficient lighting. At approximately 9:30am LPA observed Bathroom #1 on the first floor. Under the sink, stood cleaning chemicals, Comet and Spray Disinfectant. At approximately 9:35am, LPA inspected Bathroom #2 on the second floor and located cleaning chemicals under the sink. At LPA's request, Staff removed the cleaning products and placed them under the kitchen sink to be secured and inaccessible to residents in care. Bathrooms were observed to clean and appliances functional. LPA tested the temperature from the bathroom faucet, which was observed in regulated limits. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted on a monthly basis. At approximately 9:25am LPA inspected the facility's fire extinguisher on the second floor. The inspection tag indicated it was last inspected August 2021. Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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 12/15/2023 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAIRVIEW LIVING LLC	FACILITY NUMBER: 361881241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not comply with the section cited above by not ensuring the facility's fire extinguisher was inspected with in the last year; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator agrees to either have the current fire extinguisher inspected and tagged to get back into compliance or purchase a new fire extinguisher for the facility. Administrator agrees to complete this task and submit verification to the Community Care Licensing Office within the next 14 business days.

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above by not ensuring all chemicals, toxins and poisonous items were secure and kept inaccessible to residents in care; which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Staff completed this plan of correction during the visit, by removing the dangerous items from underneath the bathroom sink and placing them in a secure location.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 12

Document Has Been Signed on 12/15/2023 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAIRVIEW LIVING LLC	FACILITY NUMBER: 361881241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above in by ensuring staff on duty had CPR/First Aid Training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have all staff assigned to work at the facility trained in CPR/First Aid training, collect the verification and submit a copy of that verification to Community Care Licensing within the next 30 business days.

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not properly storing the facility's eggs. Storing the facility's eggs in a pantry at room temperature can promote illness causing bacteria to grow which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Staff made the correction during the time of the visit, by placing the eggs in the refridgerator to be properly stored.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAIRVIEW LIVING LLC	FACILITY NUMBER: 361881241
	VISIT DATE: 12/15/2023

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Posters such as; the personal rights, let-us-know, evacuation plan, theft and loss policy, house rules, infection control, meal times and disaster plans were posted in a common area. There was a designated secure storage space for resident/staff files. Medications were secure and inaccessible to residents. Emergency and first aid kits were observed and readily available for residents in care.

Food Service: LPA completed a walk trough of the facility kitchen. In the facility's refrigerator and pantries LPA observed non-perishable and perishable food supply is sufficient for number of residents in care.
At approximately 9:25am, while inspecting the facility pantry, LPA observed a container of eggs in the pantry at room temperature. LPA asked staff to store the eggs in the refrigerator during the visit.
The facility has a posted food menu; which is published on a monthly basis for breakfast, lunch, dinner and snacks. Facility offers its resident a variety of food items. Dishes, cups, and utensils were observed in proper storage and in adequate amounts. Emergency food and water supply were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members currently employed in the facility have criminal record clearance through the department.
Record Review: LPA reviewed six resident files for admission agreements, updated physician reports, and needs and services plans.

Based on observations, interviews and record reviews, deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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