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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803845
Report Date: 06/14/2021
Date Signed: 06/14/2021 11:24:21 AM

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:PARKROSE GARDENS OF FAIRFIELDFACILITY NUMBER:
486803845
ADMINISTRATOR:SEABOURNE, JASMINEFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 40DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jasmine Seaborne, AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Jasmine Seaborne, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPAs observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors. Visitors and staff are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff have a separate sign-in sheet which includes a log of their temperature. Resident's temperatures are taken during every shift (3 times) and documented daily. LPAs conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings.
Administrator stated staff clean and disinfect the facility daily. High touched surface areas are disinfected after each use. The facility has a designated visitation area, provides virtual visits and phone calls for family to stay in contact with residents.

Facility staff have completed training on donning/doffing PPE, isolation policies, and infection prevention. N-95 respirator Fit testing is in process.
LPA observed an ample supply of PPE including gloves, face shields, N-95 respirators, surgical masks, and gowns. All staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.



No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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