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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603513
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:03:46 PM


Document Has Been Signed on 06/06/2022 04:03 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:PARKWAY GARDENS RETIREMENT CARE HOMEFACILITY NUMBER:
374603513
ADMINISTRATOR:CARMINDA RAMIREZFACILITY TYPE:
740
ADDRESS:660 VAN HOUTEN AVETELEPHONE:
(619) 444-2729
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:15CENSUS: 12DATE:
06/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Althea Bardario, House ManagerTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for a deficiency that was observed during a complaint investigation. LPA was granted entry into the facility by Arthuro Vinarao, Staff, to whom she disclosed the purpose of the visit. The house manager, Althea Bordario, was called and arrived a short time later.

During a complaint investigation, LPA discovered, through interviews and record review, that Resident 1 (R1) [an LIC 811 Confidential Names List was provided to identify the resident] moved into the facility on March 13, 2022; however, an admission agreement was not executed until March 30, 2022.

Deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted, and this report was discussed with Althea Bordario. A copy of the report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to the house manager, and her signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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Document Has Been Signed on 06/06/2022 04:03 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: PARKWAY GARDENS RETIREMENT CARE HOME
FACILITY NUMBER: 374603513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited

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Evaluation of Suitability for Admission. (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (4) Execute the admissions agreement. This requirement was not met as evidenced by:
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Based on interview and review of records, licensee did not execute an admission agreement prior to admission for 1 (R1) of 13 residents. This posed a potential personal rights violation for resident 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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