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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 05:11:15 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
10/10/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221010134127
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:
03:00 PM
MET WITH:Ensuida Real, Activity DirectorTIME COMPLETED:
05:23 PM
ALLEGATION(S):
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Face masks are not being followed
Visitor sign-in log is not being followed
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-20221010134127. LPA met with Ensuida Real, Activity Director.

LPA investigated the above allegations, conducted interviews, and observations were made at Parkrose Gardens of Fairfield. Based on LPA's observations on 9/9/22, 9/19/22, 9/23/22, 10/11/22, & 1/27/23, & statements received, licensee & administrator failed to protect the personal rights of residents in care to receive safe & healthful accommodations & engaged in conduct inimical to the health, welfare, and safety of residents in care, in that facility staff failed to wear face coverings while providing care (such as feeding food & transfering) and supervision to residents in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. Additionally, LPA observed visitors, who were not wearing face masks as required, entering the facility on 01/27/2023.

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: 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 6
Control Number 21-AS-20221010134127
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
CCR
87307(d)(3)(B)
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87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply...:(3) All persons shall be protected...within the facility through provision of the following: (B) Information and instruction regarding...appropriate subjects. This requirement was not met as evidenced by:
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Licensee to submit a statement they understand reg 87307(d)(3)(B) & will be in future compliance. Additionally, submit a written detailed plan of how they will ensure staff and visitors are following CCL directives.
Statement and detailed plan to be submitted to CCL by POC due date 02/02/2023
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Based on statements and observations, the facility did not ensure the regulation above due to staff and visitors being observed without wearing a face mask over their mouth and nose as required. 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
87405(d)(2)
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87405 Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)…all requirements…shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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Administrator to submit a statement they understand reg 87405(d)(2) & will be in future compliance. Additionally, submit a written detailed plan of how they will ensure all staff & visitors are signing in and documenting being screened prior to entering the facility.
Statement and detailed plan to be submitted to CCL by POC due date 02/02/2023
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Based on statements and observations, the facility did not ensure the regulation above due to visitors not signing in the facility log (including screening log) as required. 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: 2 of 6
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
10/10/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221010134127

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:
03:00 PM
MET WITH:Marlene Bremer, Marketing DirectorTIME COMPLETED:
05:23 PM
ALLEGATION(S):
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Resident sustained unexplained injuries and bruising while in care
Facility staff did not obtain medical care for resident in a timely manner
Facility staff did not inform responsible party of resident's injuries
Facility is unclean
Facility does not provide daily activities to residents
Medication storage is accessible to residents
Facility did not provide copies of resident's documents to responsible party
INVESTIGATION FINDINGS:
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 ***AMENDED REPORT*** PG 1 of 2 Unsubstantiated

Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Parkrose Gardens of Fairfield to deliver findings on complaint # 21-AS-20221010134127. LPA met with Marlene Bremer, Marketing Director.

The Department investigated the allegations "Resident sustained unexplained injuries and bruising while in care" and "Facility staff did not obtain medical care for resident in a timely manner".
LPA investigated the above allegations: "Facility staff did not inform responsible party of resident's injuries
Facility is unclean", "Facility does not provide daily activities to residents", "Medication storage is accessible to residents"," Facility did not provide copies of resident's documents to responsible party". During the investigation, LPA conducted interviews, reviewed/obtained records, and made observations at Parkrose Gardens of Fairfield.
Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20221010134127
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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**AMENDED REPORT*** PG 2 of 2 - Unsubstantiated
The following was reported to The Department of Social Services, Community Care Licensing:

    Allegations: "Resident sustained unexplained injuries and bruising while in care"; "Facility staff did not obtain medical care for resident in a timely manner"

      On 09/26/2022, Resident (R1) was found to have moderately continued fracture of the left humeral head and neck junction from an unwitnessed ground level fall. Information received indicated R1 visited a family member on 09/25/2022. According to facility observation notes and various witness statements, it was noted that R1 complained of pain the evening of 09/25/2022. R1's left shoulder injury was discovered on 09/26/2022. R1's designated representative and primary care physician were notified. It is unknown where the injury was sustained at.

    Allegations: "Facility staff did not inform responsible party of resident's injuries"; "Facility is unclean"; "Facility does not provide daily activities to residents"; "Medication storage is accessible to residents";" Facility did not provide copies of resident's documents to responsible party".
      In addition to the above, it was reported R1's injuries were not reported to their responsible party and the facility did not provide copies of R1's documents to their responsible party. Regarding the above allegations of unexplained injuries, it is unknown where the injury was sustained at (at home or in the facility), therefore when the bruising was discovered the facility stated they informed R1's responsible party. Additionally, reports alleged the facility is unclean, medication storage is accessible to residents and daily activities are not being provided. LPA conducted inspections at the facility on 09/23/2022, 10/11/2022, and 1/27/2023. During those inspection dates, LPA observed Activity Director providing activities to residents such as arts & crafts, music, and exercises. Additionally, LPA observed the medication room to be secured with a locked metal screen door and will also have a medication cart on wheels blocking the door as a secondary barrier on those dates. At the times of inspection (09/23/22, 10/11/22, 1/27/23) LPA did not observe debris in the facility. Due to a lack of witnesses and corroborating statements, the Department was unable to prove or disprove the allegations. Records reviewed and observations did not corroborate the allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Marlene Bremer, Marketing Director, whose signature on this form confirms receipt of these documents.
No deficiencies cited regarding the above allegations of this complaint during this inspection.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20221010134127
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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During separate complaint investigation (complaint # 21-AS-20220902150010 opened on 09/08/2022), it was revealed the facility was not following the visitor sign-in log due to staff (S1) who visited the facility on 09/01/2022 and on other previous dates confirmed, S1 did not sign-in the visitor or staff sign-in log/sheet. Therefore it is not documented if S1 was screened prior to entering the facility. S1 was not associated to the facility until 09/26/2022.


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: 6 of 6