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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881241
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:54:11 PM

Document Has Been Signed on 12/11/2024 02:54 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FAIRVIEW LIVING LLCFACILITY NUMBER:
361881241
ADMINISTRATOR/
DIRECTOR:		ABDALLATEF, AHMADFACILITY TYPE:
740
ADDRESS:1089 W HUFF STREETTELEPHONE:
(909) 805-5025
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 10CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Ahmad Abdallatef, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst, LaVette Farlow, (LPA ) arrived at the Fairview Living, LLC Facility unannounced to conduct an Annual Inspections. LPA introduced self 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, Ahmad Abdallatef was notified of LPA's visit via telephone. Staff Member, Lupe accompanied LPA on a walk through of the facility and provided resident records for review.

The facility has 5 resident bedrooms, 1 staff room, 3 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 8 residents in care . The census at the time of the visit was 4, the other 4 resident were at the day program and doctor visits. 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 of 74 degrees. LPA inspected resident bedrooms and found that each room was maintained and included required furniture such as: mattresses, night stands, adequate storage space. Each room needed sufficient lighting such as lamps or a operational ceiling light, and chairs for residents in care. A technical violation was issued.

LPA observed a bathroom upstairs in a shared bedroom and the water faucet was not working. LPA notified staff and licensee. Licensee did immediately repair the faucet.

Bathrooms were observed to clean. 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 quarterly basis. LPA inspected the facility's fire extinguisher on the second floor. The inspection tag indicated it was last inspected November 2024.

Please see LIC9099-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FAIRVIEW LIVING LLC
FACILITY NUMBER: 361881241
VISIT DATE: 12/11/2024
NARRATIVE
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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. LPA observed the annual emergency and disaster plan had not been review or signed. A technical violation was issued. There was a designated secure storage space for resident/staff files. LPA observed Administration and staff files are not maintained at the facility and the Administrator Certificate has been expired since April 2024. Two (2) deficiency were cited. Medications were secure and inaccessible to residents. LPA observed one (1) out of three (3) resident MAR was incomplete. One (1) technical violation issued. LPA observed the facility does not maintain an emergency to go bags for resident in care with emergency information or contact information readily available. A deficiency was cited. LPA observed the facility does not maintain a hospice care plan for residents in care, A technical violation was issued.

Food Service: LPA completed a walk through of the facility, kitchen, the facility's refrigerator and pantries LPA observed non-perishable and perishable food supply is sufficient for number of residents in care. 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. LPA observed the facility does not maintain a emergency food and water supply in case of an evacuation for residents in care. A deficiency was cited.
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 three (3) 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 and technical violation were issued. A copy of this report was read/reviewed with Facility Administrator Ahmad Abdallatef; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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Document Has Been Signed on 12/11/2024 02:54 PM - It Cannot Be Edited


Created By: Lavette Farlow On 12/11/2024 at 02:17 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: FAIRVIEW LIVING LLC
FACILITY NUMBER: 361881241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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4
Administrator agrees to provide staff file and maintain staff records, training, personnel record, physician report etc and made readily available to CCL at the facility at all times.
Type A
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out of one (1) areas. The administrative certificate has been expired since April 2024. Administration did not complete the required step to renew certificate prior to the expiration date, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Administration agrees to complete the training/continued education hours prior to the end of December 2024.
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
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 12/11/2024 02:54 PM - It Cannot Be Edited


Created By: Lavette Farlow On 12/11/2024 at 02:17 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: FAIRVIEW LIVING LLC
FACILITY NUMBER: 361881241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in eight (8) out of eight (8) residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Administration agrees to provide emergency food to be stored and prepare the evacuation bags for residents in care.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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