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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:12:33 PM

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
11/13/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 21-AS-20231113120344
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: 41DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marlene Bremer, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staffing requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced at Parkrose Gardens of Fairfield to complete investigation and deliver complaint findings. LPA met with Marlene Bremer, Administrator LPA investigated the above allegations.

During the investigation LPA requested and obtained copies of documents from the facility. Interviews were conducted with relevant parties and observations were made.

As a result of the investigation, allegation: Staffing requirements, it has been concluded that the facility staffing requirements were not proven to be an issue at the facility. This allegation is unsubstantiated.

No deficiencies were cited regarding this allegation during today's inspection.
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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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
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
11/13/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 21-AS-20231113120344

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: 41DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marlene Bremer, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Facility in disrepair
Reporting requirements
Lack of food safety resulting in injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced at Parkrose Gardens of Fairfield to complete investigation and deliver complaint findings. LPA met with Marlene Bremer, LPA investigated the above allegations.

During the investigation LPA requested and obtained copies of documents from the facility. Interviews were conducted with relevant parties and observations were made.

As a result of the investigation, allegation: Facility in disrepair, it has been concluded that the facility roof and driveway overhang is in disrepair due to ambulance company hitting the overhang located just off the kitchen side exit door. The incident happened on October 5, 2023, which was not reported to CCLD. This allegation is substantiated.

Continue on LIC9099C
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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20231113120344
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: 11/29/2023
NARRATIVE
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Continue from LIC9099A

As a result of the investigation, allegation: Reporting requirements, administrator failed to report to CCLD on allegation facility in disrepair and lack of food safety resulting in injury. Administrator informed LPA that the facility was unaware that they needed to report the incident of the ambulance hitting the overhang which resulted in the facility being in disrepair. The administrator also stated that it is unknown as to why the incident with R1 injuring R1 was not reported to CCLD. This allegation is substantiated.

As a result of the investigation, allegation: Lack of food safety resulting in injury, it has been concluded that the facility dietary department left a piping tip in Jell-O and served to R1 unaware resulting in R1 biting down on a piping tip which resulted in R1 having pain which R1 complained to staff when the incident happened, which was not reported to CCLD. 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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20231113120344
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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
87303(a)
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(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.
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Administrator agred to get roof, cracked beams and overhang repaired. This shall be done no later than the POC date.



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Based on LPA's observation when touring the facility with the Administrator, the licensee did not comply with the section cited above by maintaining the facility in disrepair, which poses potential health and safety risk to employees.
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Type B
12/05/2023
Section Cited
CCR
87211(a)(2)
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(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(2)Occurrences, such as epidemic... major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to ... appropriate.
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Administrator and staff who are responsible for reporting incidents to read understand the regulation and submit self-certification on understanding the importance of reporting requirements.
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Based on an interview with the Administrator the serious incident report (SIR) for 2 allegations which were not reported to CCLD. Which poses potential health and safety risk to employees and 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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20231113120344
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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2023
Section Cited
CCR
87555(a)
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87555(a) General Food Service

The total daily diet shall be of the quality and ... All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator agreed to obtain a CCL approved vendor to train dietary staff on policies and procedures of regulation 87555, Administrator to submit Proof of training, including trainer, attendees, topics covered and time spent to CCL no later than POC date.
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Based on observation, photo and interview, Administrator did not ensure food was properly prepared and served in a safe and healthful manner, which poses a 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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5