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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 12/11/2025
Date Signed: 12/11/2025 02:24:55 PM

Document Has Been Signed on 12/11/2025 02:24 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARKSIDE VILLA INCFACILITY NUMBER:
435202647
ADMINISTRATOR/
DIRECTOR:		FORONDA-CAYABYAB, MARIEFACILITY TYPE:
740
ADDRESS:300 S 22ND STTELEPHONE:
(408) 831-7411
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 15CENSUS: 14DATE:
12/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Ninfa GozonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit regarding the incident that happened between two resident. LPA met with designated administrator Ninfa Gozon and stated the purpose of the visit.

On 10/22/2025, the Department received an incident report regarding intimacy between two residents. On 10/23/25 and 11/05/25 the Department conducted an investigation and interviewed R1 and R2, 2 staff and the administrator.

Based on interview, the facility staff was not aware that R1 went to R2s room without invitation from R2 at approximately 0200 hrs. R1 is high functioning, and can communicate and express his/her thought and gave his/her account of what happened. R2 is developmentally challenged, and cannot fully express himself/herself. R2 gave an unclear account if the intimacy was consensual or forced.

Based on observation and document review, R1 is high functioning and is able to verbalize and communicate clearly. R2 is developmentally challenged and is not able to articulate and give detailed account of the foregoing event.

Based on interview of staff 2 (S2) and administrator (ADM) both stated that R1 is high functioning. R2 is less verbal and has a hard time communicating and verbalizing and is not able to give account of the foregoing event.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARKSIDE VILLA INC
FACILITY NUMBER: 435202647
VISIT DATE: 12/11/2025
NARRATIVE
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Based on observation and interview, staff 1 (S1) admitted that he/she was not aware that R1 went to R2s room and had intimacy in R1s room. S1 stated that he/she was busy watching on his/her tablet and have no line of sight of the hallways from the kitchen. S1 stated that most residents were asleep in the wee hours of the morning. The kitchen was closed and his/her line of sight was obstructed. S1 stated he/she did not hear R1 and R2 walking. S1 stated that he/she is the nocturnal (NOC) shift staff and supervises residents ensuring that they are asleep and not walking around disturbing other residents.

Based on observations, interviews and document reviews. S1 did not provide care and supervision as identified in the client's needs and services plan as necessary to meet the client's needs. R2 requires care and supervision due to his/her her developmental capability and level of understanding. R1 stated he/she tiptoed to R2s room. R1 stated he/she knows that he/she is not allowed to go to the opposite gender's room without proper consent. S1 stated, he/she did not hear and see R1 and R2 walking because he/she was inside the kitchen with obstructed view of the open living area and dining area at approximately 0200 hrs.

Therefore the preponderance of evidence that there is neglect and lack of supervision is substantiated.

Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22, 85065.6 night supervision. See LIC 809D. An exit interview was conducted with designated administrator Ninfa Gozon. A copy of the report and appeals rights were provided.

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 02:24 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/11/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARKSIDE VILLA INC
FACILITY NUMBER: 435202647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
CCR
85065.6(b)

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85065.6 Night Supervision (b)Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency...This requirement is not met as evidenced by:
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stated he/she was watching on his/her tablet at the time of the incident between R1 & R2 which pose/poses an immediate health, safety and personal rights risk to persons in care.
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Based on interview & record review, the licensee did not ensure that staff was providing care and supervision from 10:00p.m to 7:00 a.m. to residents in care. When R1 tiptoed to R2s room and tiptoed back to his/her room to have sex with R2 in R1s room and S1 did not get alerted. S1
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DADM stated that he/she will submit a written plan of correction to address the NOC shift staff not being present and visible to provide care & supervisions from 10:00 pm to 7:00 a.m.. DADM willl submit plan of correction to LPA by the due date 12/12/2025.

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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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