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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803341
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:28:35 PM

Document Has Been Signed on 09/27/2024 03:28 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 3FACILITY NUMBER:
486803341
ADMINISTRATOR/
DIRECTOR:		PATRICIA T. HARLANDFACILITY TYPE:
740
ADDRESS:5248 ETRUSCAN DRIVETELEPHONE:
(707) 386-1296
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 4DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Staff Member, Maribel SaldevarTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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At approximately 12:35PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Maribel Saldevar. Licensee/Administrator, Patricia Harland, arrived during visit at approximately 12:50PM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 4 Residents in care and 1 staff member on-site.

At approximately 12:40PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:50PM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 4 Resident bedrooms,1 staff room, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected December 2023. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last disaster drill was conducted August 2024.
LPA observed that facility does not have an evacuation chair on-site per Health and Safety Code. Per discussion with Licensee, all residents live on the first floor and staff members live on the second floor (see technical advisory, LIC9102, H&S Code 1565(f)(1)).

At approximately 1:00PM, LPA reviewed staff files, resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 5
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 3
FACILITY NUMBER: 486803341
VISIT DATE: 09/27/2024
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Continued from LIC809

During medication review, LPA observed that PM medications were pre-poured. Per Licensee, PM medication was poured this morning. LPA informed Licensee that prepouring medications is out of compliance with regulation and that medications must be live-poured (see technical violation, LIC9102, regulation 87465(h)(5)).

Administrator's Certificate for Patricia Harland (7003252740) was current with an expiration date of 01/08/2026. Per discussion with Licensee, facility does not do many activities apart from birthday parties and resident walks. LPA discussed activity ideas with Licensee (see technical advisory, LIC9102, regulation 87219(a)).

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 10/27/2024.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisories/Violations) discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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