435202647-1-26-2024-26-AS-MPAA-CZV4PM-20240126181658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 01/26/2024
Date Signed: 01/26/2024 06:17:39 PM

Document Has Been Signed on 01/26/2024 06:17 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:	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: 15	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Marie Foronda-Cayabyab		TIME COMPLETED:	06:30 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) Mita Partoza conducted an unannounced required annual inspection to the facility. The inspection was originally started on 1/24/2024 and this report is a continuation of the unannounced required annual visit. LPA met with administrator (ADM) Marie Jan Foronda-Cayabyab and amended the record that was erroneously recorded at a different facility on 1/24/2024. During today's visit 1/26/2024. LPA met with ADM and 5 staff. Currently the facility has 15 residents and 15 Out of 15 are ambulatory. During visit, LPA toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, storage area, and backyard. Staff room was inspected, 2.5 bathroom were inspected. The room temperature measured at 68-75F and the hot water temperature measured from 114.6F to 117.7F LPA with ADM tested the fire alarm and carbon monoxide system and found to be in good working condition. Night lights are also observed and are in good working condition. All designated emergency exits and passage ways are clear from obstructions. LPA observed the fire extinguisher in the kitchen is missing inspection tag that needs to conform with the regulations adopted by the State Marshall. page 1 of 2 continued on page 2 (LIC 809C).

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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

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: 01/26/2024

NARRATIVE

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continued from page 1 (LIC 809)

Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be in ample supply. Toxic materials such as laundry detergent, disinfectant are inaccessible to residents and stored in a locked cabinet.

LPA observed there is ample amount of perishable food for 2 days and 7 days non-perishable food supply for residents and staff as required by regulation.

LPA and ADM reviewed 7 resident record, the resident's centrally stored medication and destruction record (CSMDR) and their P&I (cash resource) and found that all records are updated per regulations with no discrepancy.

All designated emergency exits and passage ways are clear from obstructions.

Staff and Administrator were reminded about infection control plan.

A deficiencies was cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Marie Jan Foronda-Cayabyab.

end of report
page 2 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/26/2024 06:17 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
CENTRAL COAST CR/RES, 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87230

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observaction], the licensee did not comply with the section cited above in 1 out of 1 identifiers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that the fire extinguisher will be inspected and a proof of correction will be submitted to LPA on the POC due date. The citation was discussed and reviewed by the licensee and understood.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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