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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604299
Report Date: 07/12/2022
Date Signed: 07/12/2022 04:26:18 PM


Document Has Been Signed on 07/12/2022 04:26 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:PARKSIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
134604299
ADMINISTRATOR:KAHNIS, KEVINFACILITY TYPE:
740
ADDRESS:1685 CYPRESS DRTELEPHONE:
(442) 271-4109
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:18CENSUS: 15DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Siklalic "Laly" Garcia, House ManagerTIME COMPLETED:
12:28 PM
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Licensing Program Analyst (LPA) Esther Miller, Community Health Nurse II Corina De Leon, Liason Infection Preventionist Hosniyeh Bagheri, Infection Preventionist Hilary Metcalf, Infection Preventionist Assistant Cinthya Coronado with Imperial County Public Health Department's Healthcare Associated Infection (HAI) Program conducted an on-site visit. LPA and nurse identified themselves and discussed the purpose of the visit with Siklalic "Laly" Garcia, House Manager.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, House Manager were interviewed and a walk-though of the facility was conducted. A debriefing was conducted with Administrator at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the House Manager and a copy of this report, along with Licensee Rights (LIC9058 01/16), were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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