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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804054
Report Date: 01/27/2023
Date Signed: 01/27/2023 04:42:33 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
09/02/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220902150010
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: 45DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ensuida Real, Activity DirectorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility did not receive written consent from resident or their responsible party prior to releasing resident confidential records

Facility did not safeguard resident records

Facility interrupted Hospice Care Services for resident
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-20220902150010. LPA met with Ensuida Real, Activity Director.

LPA investigated the above allegations: “Facility did not receive written consent from resident or their responsible party prior to releasing resident confidential records”, “Facility did not safeguard resident records”, “Facility interrupted Hospice Care Services for resident”. During the investigation LPA requested and obtained copies of documents from the facility and relevant parties, interviews were conducted, and observations were made at Parkrose Gardens of Fairfield.

Page 1 of 3
Report continued 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 5
Control Number 21-AS-20220902150010
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: 01/27/2023
NARRATIVE
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The following was reported to the Department of Social Services, Community Care Licensing (CCL) Division, Santa Rosa Regional Office:
    On 9/1/2022 Staff (S1) invited individuals from a group called “Direct Hospice Care” into the facility, Parkrose Gardens of Fairfield. S1 removed confidential files pertaining to residents receiving hospice services from the facility medication/file room. S1 then proceeded to copy resident’s hospice files and allowed individuals from Direct Hospice Care group to also make copies. Individuals from the group Direct Hospice Care then contacted resident’s responsible parties by phone and email informing them Parkrose Gardens of Fairfield was making a change to switch to Direct Hospice Care group for all residents receiving hospice at the facility. It was reported resident’s families/responsible parties did not consent to allow the resident’s confidential information to be copied and removed from their files at the facility. Additionally, it was reported that the incident had disrupted hospice services for residents.
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Allegation: Facility did not receive written consent from resident or their responsible party prior to releasing resident confidential records

    According to statements received from relevant parties, the facility did not have written consent from the resident’s responsible parties or Power of Attorney (POA) to remove and copy confidential resident files from the facility. Statements revealed the group Direct Hospice Care repeatedly contacted resident’s POAs by phone and email attempting to “push” POA’s to transfer residents already receiving hospice services to be under Direct Hospice Care. The resident’s POAs did not have knowledge of how Direct Hospice Care group received the hospice resident’s confidential files/information which was located at Parkrose Gardens of Fairfield.

Allegation: Facility did not safeguard resident records

    Statements received from relevant parties indicated S1 invited the group of individuals representing Direct Hospice Care into Parkrose Gardens of Fairfield and allowed the group to make and take copies of hospice resident’s files from the facility. Statements revealed the group Direct Hospice Care were also left unsupervised while the individuals made copies of resident files and while the Direct Hospice Care individuals performed assessments on hospice resident’s in their bedrooms. Although S1 denied removing resident records, making copies and providing them to Direct Hospice Care group, LPA received several corroborating statements that records were provided to Direct Hospice Care group. Additionally, LPA observed several hospice resident's files, such as hospice care plan and face sheet, to be missing from their hospice binders at Parkrose Gardens of Fairfield
Report continued on LIC9099-C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220902150010
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: 01/27/2023
NARRATIVE
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Page 3 of 3

Allegation: Facility interrupted Hospice Care Services for resident

    Statements received revealed resident POA’s were told by the Direct Hospice Care Group and Parkrose Staff (S2) that Parkrose Gardens of Fairfield had requested the transfer of hospice services to Direct Hospice Care. Statements indicated resident POA’s contacted Parkrose Gardens of Fairfield to inquire after the transfer of hospice services, but facility staff did not give POA’s a clear answer.

    POA (#1) for resident (R1) was contacted by phone from an individual with Direct Hospice Care group, who was requesting a transfer of hospice services. R1 was actively dying and already receiving hospice services from a hospice agency. POA #1 received paperwork to transfer hospice services via email from Direct Hospice Group on the evening of Thursday 09/01/2022. POA #1 signed the transfer hospice paperwork via DocuSign. POA#1 visited R1 at Parkrose Gardens of Fairfield on Tuesday 09/06/2022. POA#1 discovered R1 had been without hospice services since 09/01/2022 as R1’s hospice services were terminated with their hospice agency to be transferred to Direct Hospice Care group.

    R1's hospice services were disrupted between 09/01/2022 to 09/06/2022 as Direct Hospice Care group did not provide any hospice services during that time period. POA#1 contacted the hospice agency they were initially receiving services from and reinstated the hospice services for R1. POA#1 disclosed to LPA, that they continued to receive “harassing” phone calls, text messages and emails from the Direct Hospice Care group to transfer R1 to their services, POA#1 had declined several times to transfer hospice service providers for R1. On the morning of 09/09/2022, R1 was pronounced dead at Parkrose Gardens of Fairfield.


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Based on observations, records reviewed, and interviews conducted, the facility did not receive written consent from the resident's designated representatives/responsible party prior to releasing resident confidential records, the facility did not safeguard resident records due to providing resident's confidential information to Direct Hospice Care group which S1 invited into the facility and recommended, and the facility's actions resulted in the disruption of Hospice Care Services for resident. 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 Ensuida Real, Activity Director 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220902150010
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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited
HSC
1569.269(a)(3)
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§1569.269 Enumerated rights; severability:
(a) Residents... shall have all of the following rights:(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. This requirement was not met as evidenced by:
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Licensee to submit a statement they understand HSC 1569.269(a)(3) & will be in future compliance. Additionally, submit a written detailed plan of how they will ensure the confidential treatment of resident records and personal information.
Statement and detailed plan to be submitted to CCL by POC due date 02/02/2023
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Based on statements and records reviewed, the facility did not ensure HSC above due to releasing resident's personal information without approval of resident's responsible parties. This is a potential health, safety, and personal rights risk to residents in care.
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Type B
02/02/2023
Section Cited
CCR
87506(c)(1)
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87506 Resident Records:(c)All information and records...regarding residents shall be confidential.(1) The licensee shall be responsible...for safeguarding...all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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Licensee to submit a statement they understand the reg 87506(c)(1) & will be in future compliance. Additionally, submit a written detailed plan of how they will ensure obtaining written consent prior to releasing resident records and personal information. Statement & detailed plan to be submitted to CCL by POC due date 02/02/2023
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This requirement was not met as evidenced by:
Based on statements and records reviewed, the facility did not ensure the regulation above due to resident's hospice records which were released without approval of resident's responsible parties. This is a potential health, safety, and 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220902150010
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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited
HSC
1569.269(a)(5)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights:(5)To be accorded safe, healthful, and comfortable accommodations...
This requirement was not met as evidenced by: Based on statements & records reviewed..
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Licensee to submit a statement they understand HSC 1569.269(a)(5) & will be in future compliance. Additionally, submit a written plan of how they will ensure residents are safe/ healthful accomodations and not disrupting hospice services.
Statement and detailed plan to be submitted to CCL by POC due date 02/02/2023
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the facility did not ensure HSC above due to recommending a specific hospice group to hospice residents in the facility (who were already receiving hospice services), LPA received info R1 was without hospice services from 9/1/22-9/6/22 due to the transfer to the recomended hospice group. 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5