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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801529
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:22:40 PM

Document Has Been Signed on 02/24/2022 02:22 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:FAIRFIELD MEADOWSFACILITY NUMBER:
486801529
ADMINISTRATOR:SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:4526 TOLENAS AVENUETELEPHONE:
(707) 422-2511
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rosemarie Vister, Live-in staffTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rosemarie Vister, Live-in staff. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA conducted a walk-through of the facility with live-in staff and observed COVID-19 precaution postings. The facility has designated visitation areas for visitors. Staff and resident's temperatures are taken once a day. Rosemarie stated staff clean and disinfect the facility everyday. LPA observed 5 residents in care. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns. Staff have completed training with Solano Public Health on 2/10/22 on the following topics: infection prevention, symptoms, transmission and PPE use. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed the following requirements related to COVID-19 precautions with Rosemarie Vister, live-in staff:
    · Documenting Resident and staff daily temperatures.
    · Screening station at front entrance of facility to include a COVID-19 screening questionnaire
    · Verifying COVID-19 vaccination or COVID-19 test for indoor visitation per PIN 22-07-ASC
    · N-95 respirator Fit testing (Cal/OSHA requirement) for staff. Administrator to obtain documentation for completion for CCL verification.
    · Staff to wear face masks indoors regardless of vaccination status


Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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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: FAIRFIELD MEADOWS
FACILITY NUMBER: 486801529
VISIT DATE: 02/24/2022
NARRATIVE
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LPA observed the following unlocked & accessible medication during the inspection (photos taken):
    · 2 boxes containing 4 single-dose medication injection pens belonging to staff (S1) observed in the refrigerator
    · Clear pill box container containing 10 individual medication pills belonging to resident (R1) observed on the kitchen counter
    · 4 boxes containing topical and 1 nasal medication for residents (R2 & R3) observed in the hallway closet


The facility received a citation for the deficiency observed above.
Appeal rights given. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.





Exit interview conducted with Rosemarie Vister, live-in staff, whose signature on this document confirms receipt.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2022 02:22 PM - It Cannot Be Edited


Created By: Karina Canela On 02/24/2022 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRFIELD MEADOWS
FACILITY NUMBER: 486801529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications...(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Based on LPA's observation and interviews, Administrator due to staff leaving (staff and resident) medication unlocked and accessible to residents in care. This is an immediate health, safety and personal rights risk to residents in care.
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POC of facility plan, pictures, and statement due by 02/25/2022. Administrator to notify LPA if more time is needed.

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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 DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
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