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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801529
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:23:30 AM

Document Has Been Signed on 01/30/2024 11:23 AM - 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:FAIRFIELD MEADOWSFACILITY NUMBER:
486801529
ADMINISTRATOR:SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:4526 TOLENAS AVENUETELEPHONE:
(707) 422-2511
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chet Salvador, Administrator TIME COMPLETED:
11:36 AM
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At approximately 10;00am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management and met with Chet Salvador, Administrator.

In the course of investigating LPA learned facility does not currently offer or provide access to any activities. However, per facility's Plan of Operation, activities are offered per their activity program: cognitive and physical activities such as games and exercise that develop and maintain strength, coordination, and range of motion are supposed to be available.

Per Admin, there currently are not any activities available for the residents that would facilitate cognitive and physical activities as stated in their Plan of Operation. Per Title 22 regulation 87219 Planned Activities (i) Facilities shall provide sufficient equipment and supplies to meet the requirements of the activity program including access to daily newspapers, current magazines and a variety of reading materials. Special equipment and supplies necessary to accommodate physically handicapped persons or other persons with special needs shall be provided as appropriate (deficiency cited, see 809D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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Document Has Been Signed on 01/30/2024 11:23 AM - It Cannot Be Edited


Created By: Christi Coppo On 01/30/2024 at 10:41 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRFIELD MEADOWS
FACILITY NUMBER: 486801529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2024
Section Cited
CCR
87219(i)

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87219(i) Facilities shall provide sufficient equipment and supplies to meet the requirements of the activity program... necessary to accommodate physically handicapped persons...
This requirement was not met as evidenced by:
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Admin to purchase a variety of cognitive games and offer activities that encourage physical activity. Admin will submit LIC9098 self-certifing appropriate activities now available along with pictures of purchases and residents engaging in activities by plan of correction due date of 2/5/2024.
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Based on LPA observation and Admin confirmation facility does not currently offer or provide access to any activities, which poses a potential 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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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