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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:21:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 21-AS-20231102144058
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
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Marlene Bremer, AdministratorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not adequately supervise residents resulting in resident being physically assaulted by another resident while in care.

Staff did not ensure that resident was able to receive and make phone calls while in care.

Staff did not report an incident involving resident in care as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carol Fowler arrived to deliver findings of a complaint investigation.
During the course of investigation LPA interviewed W1 & W2, S1, S2, S3, S4, S5 & R1 & R2. Toured the facility, requested and obtained copies of facility documents and conducted record review.

As a result of the investigation, allegation: Staff did not adequately supervise residents resulting in resident being physically assaulted by another resident while in care. Altercation was witnessed by S5, LPA was informed that R3 was rapidly asking R1 for a cigarette, R1 was walking away from R3 and R3 grabbed R1’s walker and swinging at R1 (3X’s) to hit R1 but missed, R1 then hit R3 on the cheek. S5 intervened and separated the two residents. This allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20231102144058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/09/2023
NARRATIVE
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Continue from LIC9099

As a result of the investigation, allegation: Staff did not ensure that resident was able to receive and make phone calls while in care. S1 stated that all residents have the right to use the phones throughout the facility, the resident would inform staff that they would like to use the phone and staff would allow the resident to use the phone when requested. S1 also stated that if a resident is bed bound staff would then allow the resident to use one of the staff members’ work cell phone. S2 stated that the residents use the phone in S2 office and she will leave the office to give the residents privacy, per regulation the facility has telephone service on the premises. this allegation is Unsubstantiated.

As a result of the investigation, allegation: Staff did not ensure that resident was provided with clean bedding while in care. During LPA’s tour the quantity of linen was sufficient. S1 and S2 stated that linen is changed once per week or more often when needed (soiled) S1 and S2 stated clean linen is used by residents at all times. This allegation is Unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 21-AS-20231102144058

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
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Marlene Bremer, AdministratorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility is dirty.

Facility is odiferous.

Staff did not report an incident involving resident in care as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carol Fowler arrived to deliver findings of a complaint investigation.
During the course of investigation LPA interviewed W1 & W2, S1, S2, S3, S4, S5 & R1 & R2. Toured the facility, requested and obtained copies of facility documents and conducted record review.

As a result of the investigation, allegation: Facility is dirty. During LPA’s tour of the facility, LPA observed a pair of used gloves behind the door on the floor located in hallway 101 to 113. LPA also observed the dining room on the second floor had used dishes in the sink, a hamper with soiled table clothes sitting in the corner of the dining room. LPA also observed that there was a sticky substance on the dining room floor. This allegation is Substantiated.

As a result of the investigation, allegation: Facility is odiferous. During LPA’s tour of the facility, When LPA entered into the rooms the urine smell was not present, LPA smelled a strong urine smell in hallway 101 to 113 and hallway 200 to 213. This allegation is Substantiated.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20231102144058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/09/2023
NARRATIVE
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Continue from 9099A

As a result of the investigation, allegation: Staff did not report an incident involving resident in care as required. LPA received a copy of the serious incident report (SIR) from S2. LPA checked to see if the department had received the SIR, LPA could not find a copy and asked S2 if this SIR was reported to the department. LPA was told by S2 no the SIR is late and the facility had a glitch with their system. This allegation is Substantiated.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20231102144058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
11/17/2023
Section Cited
CCR
87303(a)(1)
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Maintenance and Operation 87303 (a)(1)
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement is not met as evidenced by: LPA observed the hallways had urine smells. Dining room on second floor had a sticky substance on the floor, hamper with soiled linen and used dishes in the sink. Dining room needed cleaning.
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Administrator to ensure the facility is cleaned and disinfected, Submit how the dining room will be cleaned after each use and brought into compliance and also plan on how the facility will maintain the facility per regulations. Submit plans and pictures of dining area cleaned, Submit a maintenance plan on keeping the facility free of urine odors. by POC date.
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Based on LPA's observation when touring facility with the Administrator and Wellness Director, the licensee did not comply with the section cited above in maintaining the facility in keeping the facility clean, sanitary and odor free, which poses potential health and safety risk to persons in care.
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LPA observed the hallways had urine smells. Dining room on second floor had a sticky substance on the floor, hamper with soiled linen and used dishes in the sink. Dining room needed cleaning.
Type B
11/17/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...
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Administrator agrees to have staff who are responsible for reporting incidents complete an in-service training regarding regulation 87211 no later than POC due date, and submit a copy of signed and dated log of attendance.
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Based on document review and interview with Wellness Director the serious incident report (SIR) was not reported to CCLD. which poses potential health and safety risk to persons in 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5