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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803227
Report Date: 09/20/2021
Date Signed: 09/22/2021 09:09:29 AM

Document Has Been Signed on 09/22/2021 09:09 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:FAIRVIEW COMFORT HOMEFACILITY NUMBER:
486803227
ADMINISTRATOR:HARLAND, PATRICIAFACILITY TYPE:
740
ADDRESS:609 PARADISE COURTTELEPHONE:
(707) 427-8047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Patricia Harland, Administrator TIME COMPLETED:
11:31 AM
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) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Patricia Harland, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, gloves, surgical masks, and a sign-in sheet for visitors and staff. LPA was screened for COVID-19 symptoms. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff follow indoor visitation requirement of verifying COVID-19 vaccination or a negative COVID test within 72 hours for non-essential visitors. The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with residents. Staff and resident's temperatures are taken twice a day. Staff clean and disinfect the facility twice daily. Administrator stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area.
LPA observed 6 residents in care. Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing (Cal/OSHA requirement) has been completed. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns.

The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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 1