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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801529
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:00:08 PM

Document Has Been Signed on 01/20/2023 03:00 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: 6DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rosemarie Vister, live-in staffTIME COMPLETED:
03:15 PM
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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. Administrator was unavailable during day and time of inspection. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility and observed a visitor sign-in sheet, thermometer, and hand sanitizer. The facility food supply was observed per regulation. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. During this inspection, the facility received citations and civil penalties for 3 of the various deficiencies observed. Do to time constraint, LPA will return unannounced at a later date to review additional items and complete the inspection.

LPA requested the following updated forms to be submitted to Community Care Licensing by 02/20/2023:
    · 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
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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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: 01/20/2023
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During this visit, LPA observed the following deficiencies (Photos Taken):
  • LPA observed Resident (R1)'s bed to have full bed rails. LPA explained this is not allowed as it can be used as a form of restraint . Full bed rails are prohibited unless the facility requests an exception and is approved by the Department of Social Services, Community Care Licensing. Administrator stated over the phone they will submit an exception request to be reviewed for approval.
  • During the inspection, it was revealed 1 of 2 live-in staff (S1) were out on vacation during 10/2022 to 01/11/2023. During S1's leave of absence, staff (S2) was working with individual (I1). Statements received confirmed I1 was working and providing services to residents in care during the time period mentioned. LPA verified on the facility Guardian Employee Roster and with the Santa Rosa Regional Office, Community Care Licensing, that I1 is not fingerprint cleared or associated to Fairfield Meadows.
    • LPA explained prior to anyone working, volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility (verified on the Guardian Employee Roster).




An immediate Civil Penalty in the total amount of $1000 was assessed for Individual (I1) who was working at the facility between Oct 2022 - 1/11/2023. I1 does not have a fingerprint clearance (total $500 civil penalty) and is not associated to the facility (total $500 civil penalty).


Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, 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 Staff Rosemarie Vister, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/20/2023 03:00 PM - It Cannot Be Edited


Created By: Karina Canela On 01/20/2023 at 02:04 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2023
Section Cited
CCR
87355(e)(1)

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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...as required by the Department...
This requirement was not met as evidenced by:
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Individual(I1)'s last day working int he facility was 1/11/2023. Administrator to submit a written statement that they understand the regulation and will be in future compliance. Statement to be submitted to CCL by POC due date 01/30/2023.
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Based on statements and records reviewed, Administrator did not ensure the above regulation due to Individual (I1) working and providing services in the facility without a fingerprint clearance as required. This is an immediate health, safety, and personal rights risk to residents in care.
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***An immediate civil penalty was assessed in the total amount of $500
Type B
01/30/2023
Section Cited
CCR87355(e)(2)

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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: Request a transfer of a criminal record clearance...
This requirement was not met as evidenced by:
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Individual(I1)'s last day working int he facility was 1/11/2023. Administrator to submit a written statement that they understand the regulation and will be in future compliance with associating individuals as required. Statement to be submitted to CCL by POC due date 01/30/2023.
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Based on statements and records reviewed, Administrator did not ensure the above regulation due to Individual (I1) working and providing services in the facility without being associated as required. This is a potential health, safety, and personal rights risk to residents in care.
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***An immediate civil penalty was assessed in the total amount of $500
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: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/20/2023 03:00 PM - It Cannot Be Edited


Created By: Karina Canela On 01/20/2023 at 02:27 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports: (a) ...Postural supports may be used under the following conditions. (5) Under no circumstances shall...limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited...
This requirement was not met as evidenced by:
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Licensee to request an exception for postural support - full bed rails and include supporting documentation or remove the full bedrails. Licensee to submit an exception request and supporting documents to CCL to clear the citation by POC due date 02/03/2023
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Based on statements and records reviewed, Administrator did not ensure the above regulation due to Iresident (R1) who has Full Bed Rails on their bed. S1 stated it is to prevent R1 from falling out of bed. 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 DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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