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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803227
Report Date: 11/28/2022
Date Signed: 11/28/2022 01:24:08 PM

Document Has Been Signed on 11/28/2022 01:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 5DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Patricia Harland, Licensee & AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Patricia Harland, Licensee & Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Staff have current CPR/first aid certifications in file. Fire extinguisher was charged and serviced 12/06/2021. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.
LPA verified staff COVID-19 vaccination records. The facility has an ample supply of food. LPA discussed obtaining N-95 Respirator FIT testing for staff (Cal/OSHA requirement) with licensee. During this visit, LPA and Licensee discussed updating the facility fire clearance for bedridden approval; currently the facility is only approved for 6 residents which may be non-ambulatory.
    LPA requested the following updated forms to be submitted to Community Care Licensing by 12/28/2022:
    ·     LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
    · Copy of liability insurance
    · LIC 610E Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with Administrator, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection. LPA will return to issue citations if warranted after review of files.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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