486803341-9-1-2023-21-AS-DTOA-CV9QEX-20230901120704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803341
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:07:10 PM

Document Has Been Signed on 09/01/2023 12:07 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	FAIRVIEW COMFORT 3		FACILITY NUMBER:	486803341
ADMINISTRATOR:	PATRICIA T. HARLAND		FACILITY TYPE:	740
ADDRESS:	5248 ETRUSCAN DRIVE		TELEPHONE:	(707) 386-1296
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 4	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Patricia Harland, Administrator		TIME COMPLETED:	12:15 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	9/1/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Staff, Katherine Santos. Administrator, Patricia Harland was contacted and arrived later in the visit. The facility is licensed for 6 non-ambulatory residents and a hospice waiver for 3. The facility currently provides care for 4 residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/9/2022. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Facility also follows appropriate dietary protocol for resident in care. Toxins, sharps and other items that could pose threat if readily available to residents were located in the garage and laundry room and under the kitchen sink and found to be secured. There was a supply of hygiene products, paper products and clean linens available for resident. All resident bedrooms have lighting & appropriate furnishings. Upon tour of resident bedrooms LPA observed 4 out of 4 residents with half rail beds in use. LPA confirmed that all residents have written medical clearance. Medications located in a designated closet in the hallway were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found that 4 out of 4 residents requiring updated Needs & Service Plan. Technical violation issued. LPA toured the facility backyard and found all bedroom and sliding door screens in good repair. One emergency exit located in the side yard was also found to be clear and unobstructed. Auditory alarms located at each facility exit including resident sliding door exits were found to be in working order. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRVIEW COMFORT 3	FACILITY NUMBER: 486803341
	VISIT DATE: 09/01/2023

NARRATIVE

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Upon a review of staff records, LPA found all staff to have appropriate annual and initial training as well as current 1st Aid & CPR certification on file. Upon roster review of the facility, LPA found that one staff (S1) is currently pending or "in process" for clearance on Guardian Caregiver Background Check (CBC). LPA found that the Administrator received fingerprint documentation from the Department of Justice but understood the document as a full clearance. Document was observed in S1's staff file however does not indicate that the staff was cleared. LPA and Administrator discussed a plan of action to contact CBC offices for more information on S1's clearance. S1 is to be immediately removed from the facility until properly associated. Technical Violation issued.

Administrator, Partricia Harland's Administrator Certification 6011678740 is current until 1/8/2024.

LPA was provided copies of the following updated facility documents during visit:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC309 Administrative Organization
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Surety Bond
Control of Property

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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