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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 09/19/2022
Date Signed: 09/19/2022 06:08:08 PM


Document Has Been Signed on 09/19/2022 06:08 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, 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: 39DATE:
09/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jasmine Seaborne, AdministratorTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Canela arrived at Parkrose Gardens of Fairfield for the purpose of addressing deficiencies discovered during a complaint investigation. LPA met with Jasmine Seaborne, Administrator.
During the complaint inspection, Interviews conducted revealed Individual (I1) is present in the facility on a monthly basis or once a week (most recently I1 was in the facility on 09/15/2022). LPA received information that I1 was in the facility on 09/01/2022 and 09/2/2022 reviewing resident confidential documents. LPA confirmed with the facility's Guardian personnel roster that I1 is fingerprint cleared but not associated to Parkrose Gardens of Fairfield as required. Additionally LPA observed I2 providing care and supervision to residents. I2 had been working since 07/20/2022. LPA explained prior to anyone working (including handling/making copies of confidential documents), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation in LIC809D page.
Additionally, during inspection on 09/19/2022, LPA observed resident (R1) sitting in a recliner with an activity tray table attached/locked to the recliner chair. S1 stated the tray table was attached because R1 was eating. LPA observed for 40 minutes of R1 sitting in the recliner without eating or without any food being present. S1 then disclosed the tray is locked into recliner to prevent R1 from getting up and out of the chair because R1 is a fall risk. LPA explained to staff this is a form of restraint. S1 attempted to unlock and remove the activity tray but was unsuccessful and had Individual (I2) assist with removing. Additionally LPA had to locate a staff member on the second floor twice due to residents observed needing assistance.
    *Immediate Civil Penalty in the total amount of $1000 was assessed today for two non-associated individuals $500 per individual(I1 & I2).
Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report.
Due to printer issues, this report was emailed to Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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Document Has Been Signed on 09/19/2022 06:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486804054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2022
Section Cited

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ยง1569.269 Enumerated rights; severability:(a) Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Based on observation, and interviews conducted: Facility did not ensure the above due to utilizing a table tray locked in recliner to prevent R1 from standing (Due to R1 being a fall risk) in place of proper care and supervision.
This is an immediate health, safety and personal rights risk to the residents in care.
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Facility written statement with plan to be submitted on 09/20/2022. Proof of staff training (with names of staff, signatures, date, time, duration, subject) to be submitted to Community Care Licensing by 09/26/2022.
Type B
09/26/2022
Section Cited

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87355 Criminal Record Clearance - (e)All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Based on record review, observation, and interviews conducted: Facility did not assocaitate individuals (I1 & I2) prior to working, residing or being present in the facility.
This is a potential safety and personal rights risk to the residents in care.
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**Civil Penalty assessed in the total amount of $1000.00 for individuals (I1 & I2)
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: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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