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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:45:16 PM


Document Has Been Signed on 01/31/2023 03:45 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:FORONDA-CAYABYAB, MARIEFACILITY TYPE:
740
ADDRESS:300 S 22ND STTELEPHONE:
(408) 831-7411
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:15CENSUS: 15DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marie Foronda-CayabyabTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Marie Foronda-Cayabyab.

During visit, LPA Marrufo toured the inside and outside of the facility. The facility had a visitor screening area. LPA Marrufo toured the facility kitchen and food storage areas and observed the facility to have a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed cleaning supplies at the facility.

Three out of three facility bathrooms had available soap and paper towels. The outdoor area was clear of obstructions.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Marie Foronda-Cayabyab and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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