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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540076
Report Date: 11/09/2022
Date Signed: 11/15/2022 05:53:59 PM


Document Has Been Signed on 11/15/2022 05:53 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PARKSIDE RETIREMENT HOMEFACILITY NUMBER:
380540076
ADMINISTRATOR:M. TAUFIQ ISHAQFACILITY TYPE:
740
ADDRESS:2447 - 19TH AVENUETELEPHONE:
(415) 564-6695
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:6CENSUS: 6DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Anica KoljenikTIME COMPLETED:
12:00 PM
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On 11/9/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by Caregiver, Anica Koljenik. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records, containment strategies. There are 6 residents at the facility (4 females and 2 male) and all of them have their own rooms. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap, paper towels, hand washing instruction is posted by the hand washing stations and foot operated trash cans. COVID-19 signs observed to be posted around the facility.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 6 residents, and 2 staff members present during the inspection.

During today's inspection, LPA Han requested for the following documents to be submitted to the Regional Office by 11/10/2022:
- Updated Administrator Certification
- LIC 500 (Personnel Report)

No deficiency cited today. This report is reviewed and discussed with caregiver, Anica Koljenik. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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