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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 04/25/2023
Date Signed: 04/26/2023 10:14:05 AM


Document Has Been Signed on 04/26/2023 10:14 AM - 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: 36DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marlene Bremer, Administrator & Marketing DirectorTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Marlene Bremer, Administrator & Marketing Director.
LPA toured the facility and observed it to be at a comfortable temperature. LPA observed all exits were unobstructed. Fire extinguishers were charged and serviced 08/11/2022. A total of 12 carbon monoxide detectors were tested and observed operational. LPA observed resident medication to be centrally stored and inaccessible to residents in care. Bedrooms were furnished per regulation. Food supply was within regulation.

LPA will return at a later date to review records and issue citations if warranted. LPA discussed with Administrator regulation 87608 Postural Supports and regulation 87303(i)(1)(C) Maintenance and Operation

LPA requested the following updated forms to be submitted to Community Care Licensing by 05/25/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Liability Insurance
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· LIC 9282 Infection Control Plan

Exit interview conducted with Administrator. Due to printer issues, this report was emailed to administrator
**No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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