435202647-1-2-2025-26-AS-DMAO-DCJR2B-20250102113803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 01/02/2025
Date Signed: 01/02/2025 11:38:13 AM

Document Has Been Signed on 01/02/2025 11:38 AM - 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 14	DATE:	01/02/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Sheena Angeles		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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) David Marrufo conducted an unannounced Case Management Visit and met with Sheena Angeles, Assistant Administrator. The purpose of the visit was to follow up with an incident that the facility self-reported to the Department on 11/21/2024. The incident occurred on 11/20/2024 and involved resident R1 falling to his/her knees while standing near the laundry area of the facility. Staff assessed R1 and R1 was unable to move his/her right leg. The administrator instructed staff to call 911 and R1 was taken to the hospital. At the hospital, R1 was assessed and determined to have a right femoral neck fracture. LPA Marrufo conducted a visit on 11/22/2024 and obtained copies of R1's Physician's Report, Appraisal/Needs and Services Plan, and other resident records. During today's visit, LPA Marrufo interviewed Assistant Administrator Sheena Angeles and staff S1. S1 stated to have witnessed R1 fall on 11/20/2024. S1 stated that R1 was in front of the facility washing machine and was washing his/her clothing, when R1 turned around and fell to his/her knees. S1 stated to have provided a chair to R1 to assist R1 in getting back up. S1 stated that 911 was called for R1. S1 stated that paramedics arrived at the facility and took R1 to the hospital. During today's visit, Assistant Administrator Sheena Angeles stated that R1 is still at a rehabilitation facility and is awaiting discharge to return to the facility. R1's Physician's Report was signed by R1's physician on 09/11/2024. R1's Physician's Report states R1 is ambulatory. See LIC809-C page for more information. Page 1 of 2.

Sarah Yip	TELEPHONE: (408) 324-2131
David Marrufo	TELEPHONE: (650) 380-0519
	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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 2

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: 01/02/2025

NARRATIVE

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R1 had prior falls on 01/18/2024 and 11/02/2024, which were both reported by the facility via Unusual Incident/Injury Reports. After R1's fall on 01/18/2024, staff brought R1 to the Emergency Room. R1 was not admitted to the hospital and sent back to the facility. LPA Marrufo interviewed Administrator (ADM) Marie-Janice Cayabyab over telephone during today's visit, and ADM stated that R1 was taken to R1's Primary Care Physician (PCP) on 01/30/2024. The Unusual Incident/Injury Report that reported R1's 11/02/2024 fall indicated R1's PCP advised staff to continue monitoring R1 for unusual symptoms such as dizziness or loss of balance. ADM stated during interview that staff were made aware of the PCP's advisory for R1.

ADM stated that if R1 returns to the facility with a change of condition, then R1's Appraisal/Needs and Services Plan will be updated accordingly.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Assistant Administrator Sheena Angeles and a copy of this report was provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2