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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881241
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:14:21 PM

Document Has Been Signed on 03/08/2022 01:14 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:FAIRVIEW LIVING LLCFACILITY NUMBER:
361881241
ADMINISTRATOR:NOFAL, YUSEF IZZATFACILITY TYPE:
740
ADDRESS:1089 W HUFF STREETTELEPHONE:
(646) 523-8208
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 10CENSUS: 0DATE:
03/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Yusef Nofal - AdministratorTIME COMPLETED:
12:16 PM
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility for the purpose of conducting a pre-licensing inspection visit. LPA met with Administrator Yusef Nofal. Administrator submitted a completed Pre-Licensing Self-certification checklist prior to the visit. LPA and Administrator toured the facility inside and out.

The pending initial application is for a Residential Care Facility for the Elderly (RCFE). Fire Clearance inspection was completed on 11/10/2021 and the property has been granted a fire clearance for a maximum capacity of 10, of which 2 are non-ambulatory and none are bedridden. Facility is a two story home with five bedrooms, three bathrooms, living room, dining room, and kitchen. There are no bodies of water. Appropriate patio furniture was present.

LPA observed proper required accommodations in resident bathrooms. Smoke detectors were operable. Carbon monoxide device was operable. Fire extinguisher are charged and last inspected on 8/2/2021. Hot water is kept between 105-120 degrees F. LPA observed required postings including Resident's Personal Rights, the Department's complaint poster, the Ombudsman's poster, and the facility's emergency/disaster plan.

The kitchen area was observed for the ability to serve food and cleanliness. Temperatures for refrigerator and freezer were at ideal ranges. Dishes, utensils, glasses are present and in working order. Dishwasher will be used to clean and sanitize dishes.

Bedrooms have the required furnishings and sufficient storage space and lighting. Facility has an adequate supply of linens and towel. Medication and resident and staff files will be stored in a locked cabinet and a locked box for medications needing refrigeration will be purchased and stored in the refrigerator. A complete first aid kit was observed in the kitchen. The garage will be used as a secured general storage area for dangerous objects, cleaning supplies, and toxins and will be kept inaccessible to residents.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: FAIRVIEW LIVING LLC
FACILITY NUMBER: 361881241
VISIT DATE: 03/08/2022
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LPA did not observe any potential hazards within the facility at the time of visit. The property appears to be in good repair and safe for resident use.

The Pre-Licensing Inspection is complete and the facility has no deficiencies. COMP III was completed at the conclusion of the inspection. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Administrator Nofal.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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