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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804054
Report Date: 06/22/2023
Date Signed: 06/22/2023 06:48:26 PM


Document Has Been Signed on 06/22/2023 06:48 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:MARLENE BREMERFACILITY TYPE:
740
ADDRESS:1095 EAST TABOR AVENUETELEPHONE:
(707) 422-1565
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:102CENSUS: 38DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Bill Heady, AdministratorTIME COMPLETED:
07:01 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to deliver findings on complaint investigations. LPA met with staff Arthur William "Bill" Heady, who will be taking over as Administrator.
During review of files LPA discovered Resident (R1) requires daily subcutaneous injections of insulin for Diabetes Type 2. Per resident's Physician's Report (form LIC 602) dated 04/12/2023, R1 is not able to administer their own injections. Per resident's Appraisal/Needs & Service Plan (form LIC 625) dated 10/09/2022, R1's daughter administers insulin injections for R1 twice per day. Interviews with staff confirmed this.

LPA discussed with Administrator and Wellness Director, Community Care Licensing Regulations 87628 Diabetes, 87629 Injections, 87101 Definitions, and 87616 Exceptions for Health Conditions. LPA explained resident family members are not allowed to administer medications or injections to residents in a licensed care facility, unless the resident is receiving hospice services. Medications and injections shall be administered by an Appropriately Skilled Professional, such as Registered Nurse (RN) or Licensed Vocational Nurse (LVN). The Facility was unaware of this requirement and believed family was allowed to administer injections. The facility plans to request an approved exception request from the Department of Social Services, Community Care Licensing. The facility understands that if the exception request is not approved, the facility will not be allowed to retain R1 as they can not meet their needs regarding injections.


No deficiencies cited regarding this case management inspection during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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