486804054-4-26-2024-21-AS-KMOA-D4VT4X-20240502142436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:14:06 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
09/21/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230921124054

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: 0	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Marlene Bremer, Former Administrator		TIME COMPLETED:	11:30 PM

ALLEGATION(S):

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Resident has unexplained bruising

INVESTIGATION FINDINGS:

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On 4/26/2024, Licensing Program Analysts (LPAs) Tobola and Mutialu arrived announced for the purpose of delivering complaint investigation findings and was greeted by Former Administrator, Marlene Bremer. The party had met at an outside location from the facility due to recent facility closure and Former Administrator no longer having access to the facility. The department toured the facility, conducted interviews with staff, residents and outside parties, reviewed facility and resident records and made observations during the course of the investigation.

Complaint alleges resident (R1) has unexplained bruising caused by the facility. Based on the review of R1 medical records and facility reports, there was conflicting information gathered on R1 physical behaviors towards staff and potential causes of R1 bruising. In addition, R1’s Physician and outside parties were unable to determine the cause of R1’s bruising. Lastly, based upon interviews with several staff (S1,S2,S3 & S4) there is a lack of evidence indicating R1 had been physically mistreated.
Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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-20230921124054

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: 04/26/2024

NARRATIVE

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Staff statements were consistent, involving R1 having a history of exhibiting behaviors by swinging their arms or becoming aggressive towards staff. Interviews with several residents (R2,R3 & R4) were also inconsistent, with no comment on facility care due to diagnoses of dementia. In addition, upon interview with R1, it was stated that R1 did not recall living in the Parkrose Garden facility and that staff did not hit R1. Due inconsistencies of information gathered and a lack of corroborating evidence, the allegation is found to be unsubstantiated.

A finding that the complaint allegation, resident has unexplained bruising is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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