486801529-2-14-2025-21-AS-JFLO-DDW4QZ-20250214181911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801529
Report Date: 02/14/2025
Date Signed: 02/14/2025 06:19:17 PM

Document Has Been Signed on 02/14/2025 06:19 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:	FAIRFIELD MEADOWS		FACILITY NUMBER:	486801529
ADMINISTRATOR/ DIRECTOR:	SALVADOR, MARIA		FACILITY TYPE:	740
ADDRESS:	4526 TOLENAS AVENUE		TELEPHONE:	(707) 422-2511
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	RoseMarie Vister, Designated Responsible Party		TIME VISIT/ INSPECTION COMPLETED:	06:30 PM

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	At approximately 12:00pm, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by RoseMarie Vister, Designated Responsible Party (DRP). House Manager, Christiane Salvador was contacted via telephone and arrived at facility at approximately 1:30pm. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for all non-ambulatory residents with approval for one (1) bedridden resident. At approximately 12:30 PM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices deactivated on all facility doors while two (2) dementia residents were in care. DRP activated them immediately. Additionally, rodent bait was observed in the facility entryway coat closet. House Manager states that with recent construction nearby, the facility has experienced an influx of rodent issues. Further, House Manager states that pest control have been out to the facility three times since mid-December and are scheduled to come treat the facility again soon. LPA observed worn carpeting with staining throughout the facility. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. However, LPA observed shower towels, face rags, and washcloths in client bathroom. DRP removed them immediately and agreed to ensure the facility is in compliance with regulation moving forward. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. However, two (2) of six (6) residents did not have their own designated chest of drawers for clothing storage. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
	VISIT DATE: 02/14/2025

NARRATIVE

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Continued from LIC809C...

LPA observed sharps such as two pairs of scissors and a kitchen knife not secured in the kitchen. Additionally, LPA observed a lock installed on both the refrigerator and freezer in the facility kitchen. DRP removed the locks immediately and agreed to ensure the facility operated in compliance moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPA observed uncovered meat and food in the refrigerator and freezer, as well as food that was not dated or labeled after opening or repackaging. LPA also observed two unlocked plastic storage bins with diabetic residents' insulin in the facility refrigerator. All remaining medications were observed centrally stored and locked. There is a shaded seating area in the front and backyards with outdoor space for activities. LPA observed damage to the living room ceiling consisting of two holes larger than a dollar bill and an approximately 3 foot by 12 foot section of Sheetrock damaged in the garage. House manager states that the facility was approved for a County grant for renovations and improvements to board and care facilities and the facility plans to fix these areas of concern as well as replace the flooring throughout the facility, redo the bathrooms and kitchen, and paint throughout. LPA also observed an unlocked storage shed with chemicals inside.

Residents were observed laying around for the duration of today's inspection except when performing personal hygiene or eating dinner. LPA did not observe any further activities taking place during today's inspection. Facility has internet service available to residents in care and the telephone was tested an operational during inspection.

Facility's fire extinguisher was observed charged and was last serviced 03/2024. Smoke and Carbon Monoxide detectors were tested during inspection, one (1) of which was observed missing, and four (4) others where inoperable. The remaining smoke and carbon monoxide detectors were operational during today's inspection. Facility conducts bi-annual disaster drills, and the most recent drill was conducted 11/2024. LPA informed DRP and House Manager that drill shall be conducted on a quarterly basis moving forward, and both agreed to bring the facility into compliance. LPA observed the facility's infection control plan, and facility has a first aid kit, PPE, and emergency supplies for emergency preparedness. LPA reviewed facility's emergency disaster plan which was last updated in 2003.

Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
	VISIT DATE: 02/14/2025

NARRATIVE

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Continued from LIC809C...

At approximately 2:00pm, LPA conducted file review. Facility has four (4) staff and all four staff files were reviewed. Three (3) staff files reviewed were missing proof of some or all of their training hours, two (2) staff files were observed missing proof of negative TB results, and the administrator did not have a copy of their current certificate posted or present in the facility. DRP and House Manager were unable to provide LPA with a LIC500 Staff Roster (schedule) showing who works when and how many hours per week. Two care staff live in the facility. LPA informed House Manager that the Administrator shall be present in the facility a sufficient number of hours to ensure the facility operates in compliance per regulation. All staff have proof of current First Aid and CPR certification. LPA reviewed six (6) of six (6) resident files which were each observed missing at least one (1) of the required documents. Four (4) of six (6) residents in care are under the age of 59 and the facility does not have an exception or waiver for this. House Manager states that the demographic has changed over the years and the facility may want to apply for an Adult Resident Facility (ARF) License rather than remaining a Residential Care Facility for the Elderly (RCFE).

House Manager states that the residents' family members or county case managers coordinate residents' medical and dental appointments and transportation to and from visits. However, facility staff are available to assist with transportation to these appointments as needed. Medications and medication records were inspected and the logs were observed to not be maintained in compliance with regulation, and LPA observed medications pre-poured five days ahead. Facility does not handle P&I.

LPA will return at a later date to complete this annual inspection and will issue citations and possible civil penalties at that time. No deficiencies cited during today's inspection.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
Proof of Liability Insurance (Updated)
LIC308 - Designation of Facility Responsibility
LIC610D - Emergency Disaster Plan (updated)
Current Administrator Certificate

Exit interview conducted with DRP whose signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

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