435202647-1-8-2026-26-AS-MPAA-DQ5W3L-20260108155608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 01/08/2026
Date Signed: 01/08/2026 03:56:43 PM

Document Has Been Signed on 01/08/2026 03:56 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 INC		FACILITY NUMBER:	435202647
ADMINISTRATOR/ DIRECTOR:	FORONDA-CAYABYAB, MARIE		FACILITY TYPE:	740
ADDRESS:	300 S 22ND ST		TELEPHONE:	(408) 831-7411
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY: 15		CENSUS: 14	DATE:	01/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:59 AM
MET WITH:	Marie Foronda-Cayabyab - LIC/ADM		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with the designated administrator (DADM) Ninfa Gozon and stated the purpose of the visit. Licensee/Administrator Marie Janice Foronda-Cayabyab arrived at the facility at 9:45 a.m. and left at 12:00 for a prior appointment The facility is licensed for adults 60+; up to 15 may be non-ambulatory. 6 maybe bedridden, and hospice waiver for 15. LPA observed residents and staff present, 14 out of 15 residents were out attending day program and 1 out of 15 was left at the facility and was resting at the time of the visit. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within acceptable range of 70°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 112.6°F. Bathroom water temperature ranged from 105°F to 112.6°F. Bathrooms had grab bars and non-skid mats; resident rooms had adequate storage. Medications were locked and inaccessible to residents; first aid kit was complete. Outdoor areas were free of hazards; laundry appliances were functional, and cleaning supplies were secured. Fire, smoke, and carbon monoxide systems were operational; hallways were clear and well-lit. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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)

Page: 2 of 3

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: 01/08/2026

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
26
27
28
29
30
31
32

The facility has motion sensors to alert any movements in the hallways at night time. LPA observed a storage shed at the back of the property that is used to store dry goods and a portion was converted as a activity place for residents to use.

LPA reviewed resident and staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and training. All staff have required clearances and certifications.

The facility conducts fire and earthquake drill quarterly for each shift. Last drill practice training was on 01/03/26, 1/4/26, 1/5/26. The facility is equipped with panel fire alarm system and 4 fire extinguisher were inspected on 04/21/2025.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with DADM Ninfa Gozon and a copy of the report was provided.

end of report
page 2 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3