486804054-11-29-2023-21-AS-KMOA-CYA4EJ-20231206180226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:50:23 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
10/16/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 21-AS-20231016165538

FACILITY NAME:	PARKROSE GARDENS OF FAIRFIELD		FACILITY NUMBER:	486804054
ADMINISTRATOR:	MARLENE BREMER		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:	11:11 AM
MET WITH:	Marlene Bremer, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of Care and supervision resulting in failure to seek timely medical attention for a severe injury

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Carol Fowler arrived unannounced at Parkrose Gardens of Fairfield to deliver complaint findings. LPA met with Marlene Bremer, Administrator & Marketing Director Corrina Goode.

LPA investigated the above allegation. 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: Neglect/Lack of Care and supervision resulting in failure to seek timely medical attention for a severe injury. Based on interviews, record review and investigation it has been concluded that R1 has had intermittent pain and received PRNs from hospice/facility staff. During LPA’s interview with R1 it was stated that R1 had pain but was feeling better.

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)

Page: 1 of 2

Control Number 21-AS-20231016165538

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

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
26
27
28
29
30
31
32

Continue from LIC9099

During visitation, the family has called emergency services for medical emergency resulting in R1 hospital stay on more than one occasion for observation, R1 had no complaints of discomfort and was not in distress, R1 has a diagnosis that is being treated by a Hospice Care Team per after visit summary reports. This allegation is unsubstantiated.

No deficiency cited for this allegation, 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)

Page: 2 of 2