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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:34:41 AM

Unsubstantiated


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
09/14/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230914152229
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: 39DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marlene BremerTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of supervision resulting in resident sustaining an injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced and delivers findings. This Department makes the following determinations based on interviews and documents reviews: R1 was found on the floor 07/01/2023 at 0400hrs and 911 was called; No other falls are known to have occurred at facility; R1 is considered a "high risk" for falls and uses a wheelchair and requires assists with transfers; Staff (S1) reports that R1 was agitated during the day preceding the fall; R1 was taken to bathroom by S1 at approximately 0400 hrs, 7/1 and then returned to R1's bed; Approximately 15 - 20 minutes later, S1 heard R1 call for help; R1 was found on the floor; Hospital records indicate R1 sustained an acute comminuted C1 fracture sustained from an injury resulting from ground level fall. Although the allegation that neglect/lack of supervision resulted in R1 sustaining an injury may be true, based upon the reviewed documents and statements, there is not a preponderance of evidence to prove the allegation is, or is not, true. Therefore, the allegation is UNSUBSTANTIATED.
Report left. No citations issued today.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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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