<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:10:09 PM


Document Has Been Signed on 11/09/2023 01:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PARKROSE GARDENS OF FAIRFIELDFACILITY NUMBER:
486804054
ADMINISTRATOR:MARLENE BREMERFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 40DATE:
11/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marlene Bremer, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Carol Fowler arrived at the facility for the purpose of conducting a Case Management-Incident (Incident report) follow-up inspection. LPA was greeted at the door by staff, and was granted access into the facility.

During the Case Management-Incident inspection, LPA toured facility and was made aware that a family moved a resident out and left hygiene supplies in the bathroom in a cabinet where the lock was broken. R1 was walking down the hall eating something S1 witnessed R1 and went to see what R1 was eating, it was a white bar of soap, caregiver removed the soap and reported to S2 who then attended to R1 and contacted Hospice Solano Care, Hospice doctor, S3, S4 and RP. Facility staff was instructed by hospice to provide R1 with extra fluids Hospice nurse came to the facility at 6:00pm. Facility staff was instructed to monitor the resident for 72 hours for changes.

-Deficiency observed by LPA:
Broken cabinet lock located in the bathroom of room #215.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given to the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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 11/09/2023 01:10 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
SANTA ROSA RO, 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: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
CCR
87705(a)(f)(2)

1
2
3
4
5
6
7
(a)This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia. (f)The following shall be stored inaccessible to residents with dementia:
1
2
3
4
5
6
7
Maintenance fixed cabinet lock while LPA was conducting inspection.

Administrator to ensure that all staff obtain required dementia training as the facility does have a dementia plan of operation; Submit copies of proof of training
8
9
10
11
12
13
14
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Based on LPA's observation Administrator did not comply with the section cited above which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
 for all staff to the Licensing Agency by POC correction date. Proof of training to include trainer, topics, date/time spent, attendees and staff signatures.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2