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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 04/07/2022
Date Signed: 04/07/2022 05:25:34 PM


Document Has Been Signed on 04/07/2022 05:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PARKROSE GARDENS OF FAIRFIELDFACILITY NUMBER:
486804054
ADMINISTRATOR:SEABOURNE, JASMINEFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 41DATE:
04/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jasmine Seaborne, Executive DirectorTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Karina Canela conducted a Change Of Ownership (CHOW) pre-licensing inspection and met with Executive Director Jasmine Seaborne, on behalf of applicants Align Senior Living, LLC and Atlantis FF Opco, LLC.
Jasmine Seaborne will be the Administrator once the facility is approved for licensure.
The facility has a fire clearance approval from the Fairfield Fire Department for 97 non-ambulatory and 5 bedridden (on the first floor only), for a total capacity of 102 residents. The Fairfield Fire Department has approved delayed egress. The facility has a dementia care plan which is pending approval. The facility has submitted a hospice waiver request for approval to the CAB analyst. Facility will operate with 24/7 staffing and Licensee will ensure sufficient staffing at all times.
During today’s visit LPA observed the following items:
· COVID-19 screening station with visitor log, screening questions, thermometer, hand sanitizer and verification of vaccination status
· Lockable separate storage areas for medications (med room), toxins/cleaners (storage room), and knives (kitchen).
· All exits were unobstructed; Evacuation chair at each stairwell (2 total)
· Hardwired smoke detector system, which was tested and observed operational
· 11 carbon monoxide detectors, tested and observed operational; 7 Fire Extinguishers charged and serviced 09/13/2021
· Complete first Aid kit and flashlights for emergency lighting
· Supply of paper products, hygiene supplies, extra linens available
· Grab bars in the bathrooms.
· The water temperature was tested during inspection and was within regulation of 105-120 Degrees F.
· Certificate of Liability Insurance in the appropriate amount
· Required postings: Resident Personal Rights, Theft & Loss Procedures, Visitor Policy, Rights to Resident Councils, Facility Admission Agreement; Required posting: CCLD complaint poster (PUB 475) in size 11" x 17"; Administrator ordered in the required size 20" x 26" and provided receipt as proof of purchase to LPA. Administrator to send a picture copy to LPA once received.
· Administrator to submit an update facility sketch identifying staff break room and storage rooms
Component III orientation was completed with the Jasmine Seaborne during this inspection.
Pre-licensing complete, this facility has no corrections needed
LPA will submit the CHOW pre-licensing report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of the application status.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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