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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803227
Report Date: 10/04/2024
Date Signed: 10/14/2024 03:13:18 PM

Document Has Been Signed on 10/14/2024 03:13 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRVIEW COMFORT HOMEFACILITY NUMBER:
486803227
ADMINISTRATOR/
DIRECTOR:		HARLAND, PATRICIAFACILITY TYPE:
740
ADDRESS:609 PARADISE COURTTELEPHONE:
(707) 427-8047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Rosalie Cocson, Designated Responsible Party & Patricia Harland, LIcensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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At approximately 10:10 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Rosalie Cocson, Designated Responsible Party (RP). Patricia Harland, LIcensee/Administrator was contacted and arrived at approximately 10:45 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for four (4), has two (2) Hospice residents currently in care, and is approved for all non-ambulatory residents.

At approximately 10:30 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Licensee provided proof that an evacuation chair has been ordered for the facility. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA advised House Manager and Licensee to ensure all such items are secured and inaccessible to residents when not being used. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. Facility has an internet access device available for resident use. Facility has internet available to residents in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced December 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent drill was conducted August 2024.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRVIEW COMFORT HOME
FACILITY NUMBER: 486803227
VISIT DATE: 10/04/2024
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Continued from LIC809...

LPA observed facility's infection control plan and emergency disaster plan which was last updated April 2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, flashlights and a back up generator for emergency preparedness. Licensee provided LPA with a copy of the facility's current liability insurance.

At approximately 12:00 PM, LPA reviewed three (3) staff files and six (6) resident files. Facility currently has four (4) staff but Licensee was only able to provide LPA with three (3) staff files for review (See LIC809D). Three (3) of three (3) staff files reviewed have the required paperwork and proof of current First Aid and CPR training. However, Licensee was unable to provide proof of annual medication training for two staff (See LIC809D). LPA advised Licensee to ensure proof of all staff initial, annual, and medication training is available for review upon request by Licensing. LPA also advised Licensee to ensure compliance with all initial training requirements for all new staff. Six (6) of six (6) resident files reviewed have all the required paperwork. Licensee/Administrator coordinates medical and dental visits for the residents and uses a third party transportation company to take them to their appointments.

At approximately 3:30 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. LPA advised Licensee to ensure staff are documenting medication parameters and adherence to them. Facility does not manage P&I monies.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2024 03:13 PM - It Cannot Be Edited


Created By: Julie Florio On 10/04/2024 at 04:37 PM
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: FAIRVIEW COMFORT HOME
FACILITY NUMBER: 486803227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff files requested for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee to submit a completed, signed, and dated LIC501, LIC503, proof of negative TB results, first-aid training, and proof of initial training hours for S1 to CCLD by POC due date 10/25/2024.
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee to submit proof of completion of annual medication training hours for all staff to CCLD by POC due date 10/31/2024.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


LIC809 (FAS) - (06/04)
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