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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803845
Report Date: 08/13/2021
Date Signed: 08/13/2021 04:08:38 PM

Document Has Been Signed on 08/13/2021 04:08 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, 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: 37DATE:
08/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Beverly Murcurio, Health & Wellness NurseTIME COMPLETED:
04:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a case management visit at Parkrose Gardens of Fairfield. LPA met with Health & Wellness Nurse Beverly Murcurio, regarding an incident report submitted on 06/21/2021 regarding a resident AWOL which occurred on 06/18/2021 at approximately 9:45 AM.
LPA discussed the details of the incident with the Administrator Jasmine Seaborne and Health & Wellness Nurse Beverly Murcurio. It was determined Resident (R1) may have exited through the front door as a nurse was entering the facility. The front door has an alarm with delayed egress to alert staff when memory care residents attempt to exit the facility unassisted. Staff statements revealed it takes about 30 seconds for the door to become re-alarmed and sound the alarm. It was determined R1 quickly exited the front door before the door was re-alarmed. The facility previously had a fence around the facility perimeter, which was removed in 2021. The Administrator stated North Bay Medical Center contacted Parkrose Gardens of Fairfield to notify them that R1 was found at approximately 10:30 AM. R1 was evaluated and observed to be without any injuries due to the AWOL and was returned to Parkrose Gardens of Fairfield on 06/18/2021.
Based on records reviewed, Physicians Report indicates R1 is not able to leave the facility unassisted due to diagnosis and wandering behaviors. R1's care plan dated 06/09/2021 indicates R1 has exit seeking behaviors.
R1 was monitored by staff to ensure resident's well being after the incident. R1 was put on 1 to 1 staffing to ensure safety for a week, and staff will be retrained on Supervision and AWOL Protocols.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Health & Wellness Nurse.

A civil penalty for $500.00 was assessed during today's visit due to absence of supervision.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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 2
Document Has Been Signed on 08/13/2021 04:08 PM - It Cannot Be Edited


Created By: Karina Canela On 08/13/2021 at 02:35 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARKROSE GARDENS OF FAIRFIELD
FACILITY NUMBER: 486803845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2021
Section Cited
CCR
87411(a)

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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requiement was not met as evidenced by:
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Facility to send in written plan on how they will ensure that residents do not leave the facility unassisted. Facility to train all staff regarding Care and Supervision, AWOL procedures. Staff training to include date, time of day, duration, subject, names and signatures of staff who attended.
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Based on staff interviews and records reviewed: Staff did not ensure supervision of R1, who AWOL'd from the facility without their knowledge. R1's Physician's Report(LIC 602) states R1 is not able to leave the facility unassisted,with Wandering behaviors. This is an immediate risk to the health and afety of residents care.
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Written Plan and staff training to be submitted to Coomunity Care Licensing (CCL) by POC due date 08/23/2021

Civil Penalty for $500.00 was issued during today's visit.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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