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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 11/29/2023
Date Signed: 12/14/2023 11:58:09 AM


Document Has Been Signed on 12/14/2023 11:58 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/13/2023 08:27 AM

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

NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced at Parkrose Gardens of Fairfield to deliver complaint findings on complaint #12-AS20231016165538. LPA met with Marlene Bremer, Administrator.

During the investigation LPA observed that R1's room was not clean, safe and sanitary at the time of inspection. LPA also received photos of a basin with bodily fluids, cups and a napkin on R1's floor.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Civil Penalty in the amount of $250.00 issued for repeat violation within 12 months.

****This is an amended version of the original document*****

SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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 12/14/2023 11:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/13/2023 08:41 AM

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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2023
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.
This requirement is not met as evidenced by:
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Licensee to ensure the facility is cleaned and disinfected, and R1’s bedroom is cleaned and cleared of the basin with blood, trash removed, and the floors swept and mopped.

**This is an amended version of original document******
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Based on LPA's observation when touring facility with the Administrator, and photos received the Licensee did not comply with the section cited above in maintaining a facility clean and sanitary, which poses a potential health and safety risk to persons in care.
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Submit how the bedroom was cleaned and brought into compliance and a plan on how the facility will maintain the facility per regulations. Submit plans and pictures of the area cleaned no later than the POC date. Civil penalty in the amount of $250.00 issued for repeat violation within 12 months.

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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: Carla MartinezTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2