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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803845
Report Date: 09/30/2021
Date Signed: 10/01/2021 09:28:40 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: 36DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Beverly Murcurio, Health & Wellness NurseTIME COMPLETED:
06:40 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to Parkrose Gardens of Fairfield for the purpose of delivering findings to complaint inspection. LPA met with Beverly Murcurio, Health & Wellness Nurse.
LPA toured and inspected the facility. During the visit, LPA observed Resident (R1) with a hearing aid, but was unable to hear staff. Additionally, R1 was observed eating waffles for dinner with syrup and fruit. Staff interviews revealed R1 will often request to eat waffles for dinner and will refuse to eat anything else. Health & Wellness Nurse stated R1 is diabetic. LPA requested the facility address this with R1's doctor and responsible party.

LPA requested the following to be submitted to Community Care Licensing (CCL) by 10/08/2021:
· R1's Appraisal/Needs & Service Plan
· R1's Physician Report (LIC602)
· Written plan of how the facility is addressing R1's diabetic dietary restrictions and hearing aid.

LPA will review the information.

Exit interview conducted with Beverly Murcurio, Health & Wellness Nurse, whose signature on this document confirms receipt.

Due to printer malfunction, this report was emailed to the facility.
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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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