486804054-11-29-2023-21-AS-KMOA-CYANDY-20231207092304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:03:54 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
04/24/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 21-AS-20230424162752

FACILITY NAME:	PARKROSE GARDENS OF FAIRFIELD		FACILITY NUMBER:	486804054
ADMINISTRATOR:	SEABOURNE, JASMINE		FACILITY TYPE:	740
ADDRESS:	1095 EAST TABOR AVENUE		TELEPHONE:	(707) 422-1565
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	102	CENSUS: 41	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marlene Bremer, Administrator		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Neglect/Lack of supervision resulted in pressure and unexplained injuries/weight loss

Neglect/Lack of Care resulting in resident sustaining an unexplained 2nd degree burn

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver complaint findings on 11/29/2023. LPA met with Administrator Marlene Bremer.

During the investigation LPA Karina Canela conducted interviews, observations, requested, and obtained copies of R1’s file from the facility. This complaint was forwarded to the Departments complaint investigation branch regarding allegations listed above. Investigation was conducted & completed by Community Care Licensing, Investigations Branch (IB) investigator and the following was reported. Interviews were conducted with relevant parties and observations were made.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 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)

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Control Number 21-AS-20230424162752

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 LIC9099

On the allegation: Neglect/Lack of supervision resulted in pressure and unexplained injuries/weight loss. It is concluded that during the investigation that R1 had to be hospitalized to adjust
R1’s medication, when R1 returned to the facility R1 had the pressure ulcers and facility was informed by responsible party that Kaiser home health would be taking care of R1’s wounds. R1 would at times refuse to eat and R1 would have a tendency to pace a lot and get up from the table and wouldn’t finish meals. Facility staff stated that R1 had weight loss which was reported to R1’s primary care physician and responsible party. Staff was working with R1’s primary care physician on getting a food order in place. The facility was aware of the weight loss, and it was reported to the responsible party and primary care physician, therefore this allegation is unsubstantiated.

On the allegation: Neglect/Lack of Care resulting in resident sustaining an unexplained 2nd degree burn. It is concluded that the Investigation Branch Investigator conducted interviews, observations and investigation that R1 had no access to hot beverages, R1 also had no access to chemicals while residing at the facility, chemicals are locked in one location on the first floor of the facility maintenance staff has access (keys) to the door. The investigator took water samples from several different sinks. The Investigator also inspected the water heater temperature gauge which was set at 120 degrees Fahrenheit which is within regulation, the highest water level reading was 116 degrees Fahrenheit. There is no corroborating evidence to support the allegation, therefore this allegation is unsubstantiated.

No deficiency cited for the allegations, copy of this report provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 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)

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