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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803341
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:15:55 AM

Document Has Been Signed on 07/22/2022 11:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRVIEW COMFORT 3FACILITY NUMBER:
486803341
ADMINISTRATOR:MANALO, MAGRACIAFACILITY TYPE:
740
ADDRESS:5248 ETRUSCAN DRIVETELEPHONE:
(707) 386-1296
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 4DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Magracia ManaloTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Fairview Comfort 3 for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Administrator, Magracia Manalo. LPA observed no signs on the front door regarding COVID-19 (See LIC 9102).

LPA toured the facility with the Administrator, Magracia Manalo and observed that the facility was at a comfortable temperature and was well lit. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured within acceptable range of 105 to 120 degrees F. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. Fire extinguisher was last charged on December 2021. Smoke Detectors and Carbon Monoxide Detectors were found to be operational during the inspection. First Aid kit was found to be appropriate during the inspection. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. There are special provisions made for individuals with special dietary needs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of resident’s bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supplies stored in the locked laundry room. Facility is not N95 Fit tested (See LIC 9102).

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRVIEW COMFORT 3
FACILITY NUMBER: 486803341
VISIT DATE: 07/22/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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