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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:15:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/19/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220919104947
FACILITY NAME:PARKROSE GARDENS OF FAIRFIELDFACILITY NUMBER:
486804054
ADMINISTRATOR:SEABOURNE, JASMINEFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 41DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH: Administrator Jasmine SeaborneTIME COMPLETED:
04:28 PM
ALLEGATION(S):
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Facility resident call-bell system is not functional

Facility did not observe resident's change in condition in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Parkrose Gardens of Fairfield to deliver findings on complaint # 21-AS-20220919104947. LPA met with Administrator Jasmine Seaborne.

LPA investigated the above allegations, conducted interviews, and observations were made at Parkrose Gardens of Fairfield.

Report continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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 3
Control Number 21-AS-20220919104947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARKROSE GARDENS OF FAIRFIELD
FACILITY NUMBER: 486804054
VISIT DATE: 02/07/2023
NARRATIVE
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The following was reported to The Department of Social Services, Community Care Licensing:

Allegation: "Facility resident call-bell system is not functional"

    Reports of concerns with the facility signal system were received. Currently the facility signal system consists of a button system on the resident's bedroom wall in which residents must use 2 fingers to push the buttons at the same time to activate the signal system. LPA has observed residents unable to operate the call buttons due to not knowing how to push the 2 buttons at the same time or not knowing that 2 fingers are needed to push the 2 buttons at the same time to activate the signal system. Additionally, LPA asked resident (R1), who is bedridden, how they contact staff for assistance. R1 stated they contact the front desk facility phone number, but sometimes staff do not answer the phone in a timely manner. LPA asked R1 to demonstrate if they could operate the call-bell system. The call buttons were located on the bedroom wall behind R1's bed. R1 was laying in their bed and attempted to reach the call buttons but was not able to physically reach or operate the facility call-bell system.

    Observations and statements received corroborate the allegation as the signal system does not identify the specific resident's unit when activated. The signal system displays several or all resident's bedroom numbers one after the other. Staff have disclosed they must check each resident's bedroom when the signal system is activated as the signal system does not identify the resident's bedroom where the call-buttons were pushed. The facility has 2 floors and 2 hallways/wings on each floor.


Allegation: "Facility did not observe resident's change in condition in a timely manner".

    Resident (R1) was experiencing pain in their lower abdomen. It was revealed R1 did not pass urine for approximately two days due to a catheter blockage. Staff did not observe that R1 did not have urine output in two days. During that timeframe of two days, R1 was given an over-the-counter pain relief medicine. Statements received indicated staff did not notice the empty catheter bag until R1 contacted their Home Health nurse and the facility was instructed to call for medical attention. On 09/16/2022, R1 was transported to the hospital.

The preponderance of evidence standard has been met; therefore, the allegations are found to be SUBSTANTIATED.
Appeal Rights Provided. Deficiencies cited (see LIC9099-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator Jasmine Seaborne whose signature below confirms receipt of report.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20220919104947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2023
Section Cited
CCR
87303(i)(1)(C)
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87303 Maintenance and Operation: (i)Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(C) Identify the specific resident living unit. This requirement was not met as evidenced by:
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Licensee to repair or replace the facility signal system to ensure residents are able to reach and operate the signal system independently when needing assistance. Signal system shall identify the specific resident living unit per regulation. Facility to submit their plan for the signal system to CCL by 2/14/2023 and repair or replace signal system by 03/15/2023
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Based on observations and statements received, Licensee did not ensure the regulation above due to the facility call system which is not appropriate for bedbound residents who are unable to reach the buttons, and the system does not specify which resident unit. This is a potential health, safety and personal rights risk to residents in care
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Facility to notify LPA of when correction is complete and submit pictures as proof of correction by 03/15/2023. Administrator to notify LPA if more time is needed.
Type B
02/15/2023
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided..the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any..This requirement..
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Administrator to train all staff to ensure residents are regularly monitored for changes as well as document changes and notify the resident's physician and responsible person per regulation. Proof of training to include date, time, duration, names of participants, instructor, and signatures. Staff training to be submitted to CCL by 2/15/2023
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was not met asevidenced by: Based on observations and statements received, Licensee did not ensure the regulation above due to incident of R1 who was not observed for changes by staff in a timely manner and resulted in R1 being sent to the hospital for catheter blockage. This is a potential health, safety, & personal rights risk to residents 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3