<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800353
Report Date: 07/31/2025
Date Signed: 07/31/2025 05:23:06 PM

Document Has Been Signed on 07/31/2025 05:23 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: 6DATE:
07/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Jane Frye-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 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
Licensing Program Analyst (LPA) Alviso arrived to conduct a Required-1 Year visit, on 07/31/25 at approximately 2:35pm, and met with Licensee/Administrator Jane Frye. There are currently six (6) clients in care.
Fire clearance is approved for six(6) ambulatory. Facility has a required Infection Control Plan. Facility has a required Emergency Disaster Plan. Per file review, last emergency disaster drill was conducted on 7/20/25. Facility has emergency food, water, and other supplies, to meet the "72-hour shelter in place" requirements.
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 six (6) client files. All client files had all the required documents. Client P&I money is handled by each individual client and/or responsible party; Licensee maintains balance/receipts records for three of the clients.
LPA toured the facility with the Administrator. Hot water was measured at 106.7 degrees Fahrenheit. The facility had a sufficient food supply. The facility had a sufficient supply of hygiene products, paper products, and cleaners/disinfectants, All cleaners/disinfectants were locked up and inaccessible to clients in care. All medications were locked up and inaccessible to clients in care. Fire extinguishers, two(2) were charged as required. Facility smoke alarms are hard wired, and are carbon monoxide detectors as well.. All exits were clear and unobstructed. Backyard has provided shade for clients in care. All pathways in backyard are clear of obstruction. Facility was clean and orderly. Bathrooms were clean, and all had soap dispensers and paper towels for resident use. Facility had sufficient linens and furnishings for use. Food supply was sufficient, with a variety of foods for meals and snacks, including water, juice/drinks for resident in care.
LPA is requesting the following documents to be submitted by 8/31/25:
LIC500 Personnel Report
LIC308 Designation of Responsibility
LIC610-Emergency Disaster Plan (9 pages)- if any updates submit a copy
Infection Control Plan- if any updates submit a copy
LIC400 Handling of Client Cash Resources- must be completed

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator Jane Frye.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 2