Community Care Licensing

Document Has Been Signed on 03/14/2025 02:30 PM - It Cannot Be Edited

FACILITY NAME:	FAIRFIELD MEADOWS		FACILITY NUMBER:	486801529
ADMINISTRATOR/ DIRECTOR:	SALVADOR, MARIA		FACILITY TYPE:	740
ADDRESS:	4526 TOLENAS AVENUE		TELEPHONE:	(707) 422-2511
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 6	DATE:	03/14/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	RoseMarie Vister, Designated Responsible Party		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

SUPERVISORS NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring kitchen knives, other sharp objects, and poisonous (toxic) substances were locked in their stored locations in the kitchen and outdoor storage shed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2025
	Plan of Correction
1 2 3 4	Licensee corrected this immediately the day of the initial inspection 2/14/25 by locking the cabinet in the kitchen where knives and sharp objects are kept as well as the outdoor shed where the poisonous (toxic chemicals) substances are stored. POC cleared during today's visit 3/14/25.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that all staff have proof of a negative TB test in their facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of negative TB results for S1 and S3 to CCL by POC due date 04/14/2025.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

CCR

87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that all the smoke and carbon monoxide detectors are in working order, holes in the living room ceiling are patched, and the Sheetrock in the garage is repaired which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee replaced smoke and carbon monoxide detectors that where observed inoperable during the 2/14/25 inspection. Facility has been awarded a County grant for repairs to the facility and the county is coordinating the construction project which will address the issues identified. POC cleared during today's visit.

Type B

Section Cited

CCR

87307(a)(3)(B)

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that each resident had a designated chest of drawers in their bedroom for personal use which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee has ensured that all residents have a designated chest of drawers in their bedroom since the 2/14/25 inspection. POC cleared during today's visit 3/14/25.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that a complete personnel record is maintained for each staff member which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of the noted deficient training hours, proof of negative TB results, and the Administrator's certificate to CCL by POC due date 4/14/25.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all staff have documented proof of completion of the required initial, annual, and medication training hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of all the required initial, annual, and medication training hours for S1, S2, and S3 to CCL by POC due date 04/14/2025.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

CCR

87219(a)

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above in ensuring that the facility plans and conducts regularly scheduled activities and provides a variety of options for resident engagement in activities which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit an activity schedule along with any receipts if applicable to show that the facility has been brought into compliance with offering a variety of stimulating and engaging activities for the residents in care to CCL by POC due date 04/14/25.

Type B

Section Cited

CCR

87555(b)(23)

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that food is covered, dated, labeled, and stored in compliance with regulation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of proper food handling and food safety training to CCL by POC due date 04/14/25.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025

Link to Parent Document Below:

FACILITY NAME: FAIRFIELD MEADOWS	FACILITY NUMBER: 486801529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

Type B

Section Cited

CCR

87465(h)(4)

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that centrally stored medications were properly labeled and maintained in compliance as evidenced by pre-poured medications several days in advance, refrigerated medications in unlocked plastic storage container, and logs not maintained current and accurately which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee has locked the medication plastic storage container in the refrigerator, no longer pre-pours medications and agrees to submit a self-certification to CCL by POC due date 04/14/25 which states that facility will ensure that all medications are properly stored and medications records are maintained incompliance with regulation moving forward.

Type B

Section Cited

CCR

87506(b)

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all resident records are maintained in compliance with regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee to submit signed care plans for each resident, proof of negative TB results for R1 and R2, and an emergency contact information form for both R2 and R5 to CCL by POC due date 04/14/25.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Julie Florio LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025