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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601674
Report Date: 06/17/2022
Date Signed: 06/17/2022 12:52:29 PM

Document Has Been Signed on 06/17/2022 12:52 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAIRGREEN HOUSEFACILITY NUMBER:
198601674
ADMINISTRATOR:GEORGE LOPEZFACILITY TYPE:
735
ADDRESS:2051 FAIRGREEN AVETELEPHONE:
(626) 443-1313
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff Members / Esmeralda Macias & Nathan Sierra
Health and Services Coordinator / Elsa Montes
Administrator / Administrator / Genny Guadalquivir		TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff Members / Esmeralda Macias and Nathan Sierra and was later joined by the Health and Services Coordinator / Elsa Montes and Administrator / Genny Guadalquivir who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for Three (3) Ambulatory and One (1) Non-Ambulatory Clients. Currently, there are four (4) clients in placement. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: Four (4) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, and indoor/outdoor activity areas. All medications for clients who need assistance are kept locked and inaccessible to other clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins and knives are in a secured cabinet and inaccessible to clients. There is a functioning telephone on the premises. The facility has central air and heating accommodations. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674
VISIT DATE: 06/17/2022
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The washer and dryer are located outside by the garage area. There is a detached two car garage with additional storage of food supply. The garage door is kept locked and inaccessible to clients at all times.

The following concern was observed during today's visit;
  • At 10:41am, LPA tested the hot water temperature in common bathroom #2 and it was measured at 134.4 degrees F.



The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2022 12:52 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 06/17/2022 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement is not being met as evidenced by:
At 10:41am, LPA tested the hot water temperature in common bathroom #2 and it was measured at 134.4 degrees F.
This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


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