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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800353
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:18:38 PM

Document Has Been Signed on 08/21/2024 04:18 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:FAIRWAY PLACEFACILITY NUMBER:
496800353
ADMINISTRATOR/
DIRECTOR:
FRYE, JANEFACILITY TYPE:
735
ADDRESS:4796 FAIRWAY DRIVETELEPHONE:
(707) 588-2788
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Licensee/Administrator- Jane FryeTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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LPAs Loera and Alviso arrived to conduct a Required-1 Year visit, on 08/21/2024 around approximately 1:45p. LPAs met with Licensee/Administrator Jane Frye. There are currently five(5) clients in care.

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, last fire drills, fire & evacuation were held on 06/17/2024.

LPAs toured the facility with the Administrator. Hot water was checked and recorded at 109.2F. 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 last serviced on 07/03/2024. Smoke alarms, sixteen(16) were all working properly when checked during the inspection; Six(6) of the sixteen(16) smoke alarms are carbon monoxide detectors. All exits were clear and unobstructed. Backyard has provided shade for clients in care. All pathways in backyard are clear of obstruction.

LPAs 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.
LPAs reviewed five(5) client files. All client files had all the required documents.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash
Copy of Surety Bond
Emergency Disaster plan

No Deficiencies cited during todays inspection.

Exit interview conducted with Administrator and a copy of this report was provided.



SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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