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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800353
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:17:11 PM

Document Has Been Signed on 07/25/2023 04:17 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:FAIRWAY PLACEFACILITY NUMBER:
496800353
ADMINISTRATOR:FRYE, JANEFACILITY TYPE:
735
ADDRESS:4796 FAIRWAY DRIVETELEPHONE:
(707) 588-2788
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 5DATE:
07/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Jane Frye-AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Alviso arrived to conduct a Required-1 Year visit, on 7/25/23 at approximately 2:18pm, and met with Licensee/Administrator Jane Frye. There are currently five(5) clients in care. All five(5) clients were at day program.

Fire clearance is approved for six (6) ambulatory. Facility has a required Infection Control Plan. Facility has an Emergency Disaster Plan as required. Per record review, last fire drills, fire & evacuation, were held on 6/18/23 and 6/24/23.

LPA reviewed three(3)staff files. All staff had required criminal record clearance. All staff had required annual training. All staff had current first aid, and CPR certification. All staff files were complete. LPA reviewed five client files. All client files were complete.

LPA toured the facility with the Administrator. Hot water ws checked at 106.1F. The facility had a sufficient food supply. The facility had a sufficient supply of hygiene products, cleaners/disinfectants, and paper supplies. All cleaners/disinfectants were locked and inaccessible to clients in care. All medications were locked and inaccessible to clients in care. Fire extinguishers, two(2) were serviced and tagged as required. The smoke alarms, sixteen(16) were all working properly when checked during the inspection; Six(6) of the sixteen(16) smoke alarms are also carbon monoxide detectors, All exits were clear and unobstructed.

LPA requested the following forms be submitted by 8/25/23:
Personnel Report
Designation of Responsibility
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan

There are no deficiencies cited today.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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