134604299-8-4-2021-08-AS-AVOO-C5KW3R-20210804165619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 134604299
Report Date: 08/04/2021
Date Signed: 08/04/2021 04:56:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARKSIDE VILLA ASSISTED LIVING		FACILITY NUMBER:	134604299
ADMINISTRATOR:	KAHNIS, KEVIN		FACILITY TYPE:	740
ADDRESS:	1685 CYPRESS DR		TELEPHONE:	(442) 271-4109
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY:	15	CENSUS: 15	DATE:	08/04/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Licensee, Kevin Kahnis		TIME COMPLETED:	02:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alexandre Vo, conducted an announced Pre-Licensing visit regarding the application for Change of Capacity. LPA met with Licensee, Kevin Kahnis, and Administrator, Quetzalli Kahnis, and was allowed entry into the facility after identifying himself and stating the purpose of the visit. Facility currently serves fifteen (15) elderly residents and request to increase the capacity to eighteen (18) elderly residents, ages 60 and above. This facility houses nine (9) bedrooms and four (4) bathrooms for residents' use. The Fire Clearance was approved on July 26, 2021 for ten (10) non-ambulatory residents and eight (8) bedridden residents who are to be housed in rooms number one (1), two (2), five (5), and seven (7). Facility has an approved hospice waiver for one (1). Facility serves residents diagnosed with dementia. Facility has two (2) kitchen staff and four (4) caregivers on shift during the visit. A tour of the facility was conducted inside and out. LPA was accompanied by Licensee, Kevin Kahnis, and Administrator, Quetzalli Kahnis during the inspection. According to the Licensee, the facility does not keep firearms, ammunition, or dangerous items on the property. The pool is fenced, has a self-closing latch, and is inaccessible to residents. There is a locked centralized storage area for medication and for confidential residents and staff files. The facility is clean and in good repair. Smoke alarms and carbon monoxide detectors are operational. The facility has a call pendant for residents and plan to obtain pendants for each resident upon capacity increase approval. Facility’s temperature was set at 78 degrees Fahrenheit. Hot water temperatures were measured at 110, 114, and 120 degrees Fahrenheit at faucets for residents’ use. There is appropriate furnishings including lighting, hygiene products, beds, storage capacity, clean linens in good repair. Indoor and outdoor passageways are free of obstruction. There are non-slip materials on rugs. Bathrooms are equipped with grab bars, non-skid mats, and showers, sinks, and toilets are operational. Chemicals and cleaning solutions are inaccessible to residents and are stored separate from the food supply. There is a seven-day supply of non-perishable food items, and a two-day supply of perishable food items. There is a shaded outdoor activities area. First aid and emergency supplies are present. Auditory devices are in place to monitor exits.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
	VISIT DATE: 08/04/2021

NARRATIVE

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Residents' special health care needs were reviewed.

Required postings were observed to be placed in prominent areas, which include emergency exit plan, Resident’s Council, resident’s rights, facility’s visitation policy, the Department’s complaint poster, theft and loss policy, and information for the Long-Term Care Ombudsman. The certified administrator’s certificate is current through July 24, 2022. Surveillance cameras are in use in common areas and are reflected in the Facility Sketch, Plan of Operation, and residents’ admission agreement.

The Plan of Operation was reviewed with the Licensee and Administrator. The facility has a designated activities director. Component III was waived. No deficiencies were observed during today’s visit.

An exit interview was conducted. The Licensee was informed that the report will be forwarded to management for approval. A copy of this report and Licensee’s Rights (9058 01/16) were provided to the Licensee by electronic mail. An e-mail confirmation receipt was requested.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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