134604299-2-26-2024-08-AS-AROS-D2TVF5-20240226152323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 134604299
Report Date: 02/26/2024
Date Signed: 02/26/2024 03:23:36 PM

Document Has Been Signed on 02/26/2024 03:23 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARKSIDE VILLA ASSISTED LIVING		FACILITY NUMBER:	134604299
ADMINISTRATOR:	SIKLALIC GARCIA		FACILITY TYPE:	740
ADDRESS:	1685 CYPRESS DR		TELEPHONE:	(442) 271-4109
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY:	18	CENSUS: 13	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Siklalic Garcia, care giver		TIME COMPLETED:	03:25 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) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility Siklalic Garcia, care giver , after identifying herself and stating the purpose of the inspection. The facility serves 18 elderly residents, age 60 and above, all whom may be non-ambulatory. . LPA was accompanied by House Manger Angelicia Quintero , for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. Exterior and interior passageways were free from obstructions. Pendants (call buttons) are present at the facility. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medications were locked and medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA reviewed multiple staff records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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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Document Has Been Signed on 02/26/2024 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

97458(a)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 of 5 persons which poses/posed a potential health risk to persons in care.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Licensee Agrees to complete R1 and R2 Medical assesment by POC date. Licensee agrees to submit copies by email R1 and R2 medical assesment to CCLD by POC due date

Section Cited


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

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
	VISIT DATE: 02/26/2024

NARRATIVE

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[Continued from 809]

According to the House manager food supply is cooked and delivered from another facility for breakfast, lunch, and dinner. LPA observed a few small containers of ready to eat food in the refrigerator and fresh fruit on counters however, facility has did not have two-day supply of perishable and a seven-day supply of nonperishable food items.

After LPA review of multiple staff residents licensee did not obtain and keep on file documentation of a medical assessment for some residents in care. During a tour of the facility LPA observed water tap temperature. Bathroom tap temperature was not complaint but was adjusted while LPA was present.

Based on today’s inspection, deficiencies were observed at this time in the areas evaluated. These deficiencies are listed on the attached LIC 809-D, and cited in accordance to the California Code of Regulations, Title 22, Division 6.

A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), 809-d's, and were provided to , Siklalic Garcia, care giver. whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 which poses/posed a potential health and safety risk to 13 of 13 persons in care. Freezer garage, pantry or refridgerator did not adquate supply of food to meet required minimum.
	POC Due Date: 03/05/2024
	Plan of Correction
1 2 3 4	LPA Called Licensee. Licensee agreed to purchase 7 days worth of perishable and 2 days of non-persighable food and store on site. Licnesee and LPA discussed the purchase of Emergency supply food with a long shelf life. Licennsee will provide receipt and photos in an email by POC date.

Type B

Section Cited

HSC

87303(e)(2)

87303(e)(2)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 2 of 4 bathrooms which poses/posed a potential safety risk to 13 of 13 persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Facility had 3 water heaters. Water heater was adjusted while LPA was present. Hot water in all taps were compliant before LPA left premisis.

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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