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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 03/14/2023
Date Signed: 03/14/2023 05:10:12 PM


Document Has Been Signed on 03/14/2023 05:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 FAIRFIELDFACILITY NUMBER:
486804054
ADMINISTRATOR:SEABOURNE, JASMINEFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 39DATE:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marlene Bremer, Marketing DirectorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced for the purpose of amending an unsubstantiated complaint report (21-AS-20221010134127) issued on 01/27/2023. LPA met with Marlene Bremer, Marketing Director.

Additionally, LPA followed up on a case of bedbugs at the facility in resident (R1)'s bedroom which was reported on 03/13/2023 to the Department of Social Services, Community Care Licensing. Facility immediately removed all furniture in the resident's bedroom, R1 and roommate resident (R2) were relocated to a vacant room with new furniture. Facility stated R1 & R2's responsible parties were contacted. Pest control was contacted and arrived on 03/13/2023. R1 and R2 were checked by facility Director of Wellness nurse. Pest control to conduct heat treatment and check all resident bedrooms to ensure they are cleared on 03/15/2023. LPA requested documentation to be submitted upon completion.

Moreover, during inspections on 03/13/2023 and 03/14/2023, LPA observed odors of urine in several resident bedrooms (bedroom numbers provided to Marketing Director) and main sitting area in the upstairs portion of the building (second floor). LPA discussed that although residents maybe incontinent, the facility must remain free of odors. Marketing Director stated the facility is scheduled to have deep cleaning of hallway carpets and training on cleaning for the upstairs level of the facility building.
Report continued on LIC809...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/14/2023
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During LPA's inspection on 03/13/2023, LPA observed Individual (I1) in the facility handling resident medication in a medication cart near the dining room. LPA confirmed on the facility's Guardian personnel roster printed on 03/13/2023 and 03/14/2023 that I1 is not fingerprint cleared and not associated as required. Additionally, LPA confirmed with the Santa Rosa Regional Office, office technicians, that this information is correct and I1 will need to be fingerprint cleared and associated to the facility in order to be cleared to work in a licensed facility.

LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.

Marketing Director stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at a licensed facility, the individual must obtain a fingerprint clearance and be associated to the facility.

Immediate Civil Penalty in the total amount of $100 was assessed today:
  • $100 for an non-fingerprint cleared/non-associated individual.



Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Marlene Bremer, Marketing 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: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/14/2023 05:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2023
Section Cited

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87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement was not met as evidenced by:
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Facility to submit a written plan of how they will ensure individuals are cleared and associated prior to beginning work or training in the facility & a statement I1 will not return to work or training until cleared and associated to the facility as required. Plan and statement due by POC due date 03/15/2022 to Community Care Licensing
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Based on record review, observation, and interviews conducted: Facility did not ensure individual (I1) was fingerprint cleared and associated prior to working, training or being present in the facility.
This is a potential safety and personal rights risk to the residents in care.
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**Civil Penalty assessed in the amount of $100.00
Type B
03/21/2023
Section Cited

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87625 Managed Incontinence - (b) ...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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Facility to submit a written plan of how they will ensure the facility is clean and free or any odors per regulation. Plan due by POC due date 03/17/2022 to Community Care Licensing
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Based on observations and interviews conducted: Facility did not ensure the regulation above due to resident bedrooms and hallway on second floor to have odors of urine.
This is a potential health, safety, and personal rights risk to the 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: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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