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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803227
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:34:55 PM


Document Has Been Signed on 10/06/2023 03:34 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:FAIRVIEW COMFORT HOMEFACILITY NUMBER:
486803227
ADMINISTRATOR:HARLAND, PATRICIAFACILITY TYPE:
740
ADDRESS:609 PARADISE COURTTELEPHONE:
(707) 427-8047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Patricia Harland, AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 10/06/2023 at approximately 1:15am, and met with Patricia Harland, Administrator. Certificate, #6011678740, is current- expires 01/08/2024. LPA observed two caregivers working at the time of arrival. There are currently five (5) residents in care.

Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on 9/15/2023. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

All exits were free and clear of obstruction. Fire extinguisher, was last serviced on 12/9/2022 and tagged as required. LPA observed ten (10) smoke alarms and one (1) carbon monoxide detector, working properly during the inspection.

Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 107.0 F, which is within regulation. Medications were stored and locked making them inaccessible to residents.

There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable for residents in care.



Continue on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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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: FAIRVIEW COMFORT HOME
FACILITY NUMBER: 486803227
VISIT DATE: 10/06/2023
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Continue from LIC809

There are currently five (5) residents in care. LPA reviewed three (3) of five (5) resident files; All resident files were found to be complete.

LPA reviewed three (3) staff files. LPA reviewed staff training. All three (3) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 10/16/2023:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan
Control of property
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited during inspection. Exit interview conducted with the Administrator. Copy of this report provided

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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