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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803845
Report Date: 11/22/2021
Date Signed: 11/22/2021 02:34:09 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Karina Canela
COMPLAINT CONTROL NUMBER: 21-AS-20210617112858
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: 38DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jasmine Seaborne, AdministratorTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Facility staff did not inventory resident's personal property

Facility staff did not report unusual incidents as required

Facility staff did not allow resident to have visitations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived at Parkrose Gardens of Fairfield on 11/22/2021 for the purpose of delivering findings on complaint # 21-AS-20210617112858. LPA met with Administrator Jasmine Seaborne.

LPA investigated the allegations of “facility staff did not inventory resident's personal property”, "facility staff did not report unusual incidents as required" and "Facility staff did not allow resident to have visitations". During the investigation, LPA conducted interviews, obtained and reviewed records, reviewed the facility file, and inspected the facility.

Report continued on LIC9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20210617112858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803845
VISIT DATE: 11/22/2021
NARRATIVE
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LIC9099-C page 2

Allegation - facility staff did not inventory resident's personal property: It was alleged the facility did not inventory resident (R1)’s personal property. Interviews indicated R1’s closet contained several suits, button-up dress shirts, slacks, boxes of shoes, a leather jacket, and other personal items. Interviews conducted and record review revealed the facility did not have proof or record of R1’s personal property being inventoried upon admission to the facility on 03/23/2020. Additionally, the facility stated an inventory check-list form was done upon discharge of R1's items to R1's responsible party, but could not locate a copy to provide to LPA.

Allegation - facility staff did not report unusual incidents as required: It was also alleged staff did not report unusual incidents as required. Statements obtained corroborated the allegation, as the facility did not report some incidents regarding R1 to Community Care Licensing (CCL). Incidents documented in R1's file which were not reported to CCL include: unwitnessed fall resulting in cut on left eyebrow (dated 12/03/2020 and 12/25/2020), skin tear on left elbow (dated 12/14/2020), unwitnessed fall and skin tear on left elbow – diagnosis: fall (dated 01/16/2021), and “huge skin tear on left elbow” (dated 02/16/2021). Interviews revealed the facility thought if a resident was on hospice, they would only report to the hospice agency and not have to report incidents to CCL. Record review indicated R1 was placed on hospice on 01/26/2021.


Report continued on LIC9099-C...
page 3
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20210617112858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803845
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements: (a) Each icensee shall furnish...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7days of the occurrence of any of the events specified in (A) through (D)... This requirement was not met as evidenced by:
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Facility to send in written plan on how they will ensure the regulation 87211(a)(1) and be in future complaince.
Written Plan to be submitted to Community Care Licensing (CCL) by POC due date 12/01/2021
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Based on interviews and records reviewed: Staff did not ensure incidents regarding Resident (R1) were reported to CCL as required. This is a potential risk to the health and safety of residents care.
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Type B
12/01/2021
Section Cited
HSC
1569.153(d)
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§1569.153 Theft and loss program; standards, property inventories and surrender of personal effects;secured areas: A theft and loss program shall be implemented…shall include...(d) A written resident personal property inventory is established upon admission & retained during the resident's stay...
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Facility to send in written plan on how they will ensure Health & Safety Code 1569.153(d) and be in future complaince.
Written Plan to be submitted to Community Care Licensing (CCL) by POC due date 12/01/2021
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This requirement was not met as evidenced by: Based on interviews and records reviewed, staff did not ensure Resident (R1)'s personal belongings were inventoried as required. This is a potential risk to the personal rights of residents care.
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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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20210617112858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803845
VISIT DATE: 11/22/2021
NARRATIVE
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LIC9099-C page 3

Allegation - facility staff did not allow resident to have visitations: It was reported the facility staff did not allow R1's responsible party to visit with R1 inside the facility between 04/01/2020 to 03/24/2021. Interviews and records reviewed revealed R1's responsible party was provided alternative communication options and R1's responsible party visited outside the facility through the fence, received phone calls, and virtual visits. According to Community Care Licensing (CCL)'s Provider Information Notice (PIN) 20-38-ASC dated 10/06/2020 under section E. Statewide Waiver of Licensing Standards for Visitation - Visitation Waiver, waived visitation requirements except for essential visits listed on page 12 and 13 of the PIN.
PIN 20-38-ASC states under Indoor Visitation,that "at all times when visitation is restricted under this waiver, licensees must allow indoor visits on the facility premises when all of the following requirements are met: 1.) There are no new transmissions of COVID-19 at the facility for 14 days. 2.)The facility is not experiencing staff shortages. 3.) The facility has adequate supplies of PPE and essential cleaning supplies" (page 12-13 on PIN 20-38-ASC). Additionally, page 13 on PIN 20-38-ASC states best practices recommended for indoor and outdoor visits include, but are not limited to, having a dedicated visitation area (allowing for 6ft distance between residents and visitors), face coverings, cleaning and disinfecting visitation areas after each use (additional indoor visitation best practices listed on page 14 of PIN 20-38-ASC). Records reviewed revealed dates when the facility did not have COVID-19 cases and indoor visitation was to be permitted during April 2020 - June 2020, August 2020, and 02/28/2021 - up until R1's death on 03/24/2021. During that time, R1 was permitted to have indoor visitation from loved ones on 03/24/2021. The facility staff stated they were following COVID-19 precautions and believed indoor visitation was restricted under PIN 20-38-ASC to essential visitors only. Staff interviews revealed they believed non-essential compassionate care (such as end-of-life) indoor visits were allowed following the release of PIN 21-17-ASC dated 03/19/2021. Staff interviews revealed they notified R1's responsible party some time after 03/19/2021 (specific date not known) that they could visit with R1 inside the facility. R1's responsible party visited in R1's bedroom at Parkrose Gardens of Fairfield with R1 on 03/24/2021.

Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 9099D. 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 Administrator Jasmine Seaborne, whose signature below confirms receipt of these documents.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Karina Canela
COMPLAINT CONTROL NUMBER: 21-AS-20210617112858

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: 38DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jasmine Seaborne, AdministratorTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal property

Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived at Parkrose Gardens of Fairfield on 11/22/2021 for the purpose of delivering findings on complaint # 21-AS-20210617112858. LPA met with Administrator Jasmine Seaborne.

LPA investigated the allegations of “Facility staff did not safeguard resident's personal property" and "Resident sustained multiple falls while in care". During the investigation, LPA conducted interviews, obtained and reviewed records, reviewed the facility file, and inspected the facility.

Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20210617112858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803845
VISIT DATE: 11/22/2021
NARRATIVE
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Allegation - facility staff did not safeguard resident's personal property: It was reported the facility staff did not safeguard resident (R1)'s personal property of the following missing items: "17 suit bags containing 12 suits (including 3 Italian made), 5 sports coats (2 navy, 1 black, 1 grey, 1 plaid), 5 dress slacks coordinated with the sports coats in each suit bag, 15+ dress suits, 4 quality leather belts, 3 sweaters" which estimated to a total of $12,065.00. It was reported there were 5 empty suit bags in boxes of various clothing items and the labels did not match the contents of the suits bags and were "ripped open". Interviews revealed R1 had a full closet containing several suits, button-up dress shirts, slacks, boxes of shoes, a leather jacket, and other personal items. Staff described R1 as a dressing "very sophisticated" and an "elegant person" from their wardrobe. Interviews indicated staff saw a leather coat, several suits, shoe boxes, dress shirts & slacks, among R1's personal belongings. Due to a lack of inventoried list of R1's belongings, it is unclear what items were at the facility or which items were returned or missing. Additionally the facility stated items in R1's room were returned to R1's responsible party upon discharge and do not have record of R1's items listed above being at the facility or going missing.

Allegation - resident sustained multiple falls while in care: It was reported Resident (R1) had "4 falls between 12/28/2020 and April" while at Parkrose Gardens of Fairfield. Review of R1's medical records and facility's resident appraisal did not disclose R1 being a fall risk. It was documented R1 sustained some falls and records revealed the facility reported to R1's primary physician (but failed to report to CCL).


Based on interviews conducted and records reviewed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited regarding the allegations “facility staff did not safeguard resident's personal property" and "resident sustained multiple falls while in care".
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20210617112858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803845
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
HSC
1569.269(a)(24)
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1569.269 Enumerated rights; severability: (a) Residents... shall have all of the following rights:(24)To consent to have relatives and other individuals of the resident’s choosing visit during reasonable hours, privately and without prior notice. This requirement was not met as evidenced by:
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Facility to send in written plan on how they will ensure Health & Safety Code 1569.269(a)(24) and be in future complaince.
Written Plan to be submitted to Community Care Licensing (CCL) by POC due date 12/01/2021
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Based on interviews and records reviewed: Administrator did not ensure Resident (R1)'s responsible party to visit indoors when permitted. This is a potential risk to the personal right's of residents care.
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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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7