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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202731
Report Date: 01/29/2024
Date Signed: 01/29/2024 05:48:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/29/2024 05:48 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 VILLAS IFACILITY NUMBER:
435202731
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:328 S. 22ND STREETTELEPHONE:
(408) 297-1721
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 15CENSUS: 15DATE:
01/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Ninfa Gozon and Marites ConcepcionTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced required annual inspection to the facility. LPA met lead staffs Ninfa Gozon and Marites Concepcion. Administrator (ADM) Mariie Jan Foronda-Cayabyab is currently unavailable during the visit due to previous appointment and has given consent to the Ninfa Gozon and Marites Concepcion, LIC 308 was presented. 7 out of 15 clients were present during the visit and 6 out of 15 are not in the facility.

During visit, LPA toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, storage area, and backyard. Staff room was inspected, 3 resident bathroom were inspected. The room temperature measured at 68-75F. Kitchen hot water temperature measured at 112.4F, bathroom hot water temperature measured at 111.7 to 112.4F. All rooms are clean and well maintained. The resident's room have sufficient storage for personal belongings, well lighted and sheets are clean.

LPA observed there is sufficient amount of 2 days perishable and 7 days non-perishable food supply for residents and staff as required by regulation. 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 stored in a locked cabinet. LPA reviewed facility emergency exits. 2 designated emergency exits are clear from obstruction. Three resident's bedroom (B1, B8 and B3) have emergency exit doors and are clear from obstructions.

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continued to LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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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 VILLAS I
FACILITY NUMBER: 435202731
VISIT DATE: 01/29/2024
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Continued from page 1 of LIC 809
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LPA randomly reviewed 3 out of 15 resident's record, for medication, and for safeguard of cash resources and found the record updated and accurate. LPA reviewed 2 staff records found the information are up to date. Disaster training is up to date.

No deficiencies were cited per California Code of Regulations Title 22 during today's visit. This report was reviewed with lead staffs Ninfa Gozon and Marites Concepcion and a copy was provided.

End of Report
Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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