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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202731
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:34:13 AM

Document Has Been Signed on 01/23/2025 11:34 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 VILLAS IFACILITY NUMBER:
435202731
ADMINISTRATOR/
DIRECTOR:		FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:328 S. 22ND STREETTELEPHONE:
(408) 297-1721
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 15CENSUS: 15DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Staff (S1) Ninfa GozonTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Staff (S1) Ninfa Gozon. LPAs explained the purpose of visit.

During visit, LPA's toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA's observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA's observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator was measured with thermometer at 40 degrees F and freezer at 0 degrees F. Room temperature measured at 72 degrees F.

LPA's toured eight resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA's observed several resident bedrooms with dust and grime in windows and furnishings. S1 instructed staff to clean during visit. S1 tested the smoke detectors in the hallway and found the smoke detector to function properly when tested. LPA's toured resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 114-119 degrees F.

During tour LPA's observed S2 working and asked his/her name. LPA's reviewed LIS536 Facility Personnel Summary. Based on review S2 is not associated with the Facility, S1 stated S2 has been working at this facility since 2023.

LPA's toured the outside area and found the exits to be clear of obstructions. LPAs observed 3 sheds being used for storage and not living quarters. LPA's observed 2 fire extinguisher was last serviced on 04/24/24. LPAs reviewed Fire and Earthquake log and last disaster drill was last conducted on 12/19/2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: 01/23/2025
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LPA's reviewed resident records for 4 residents. LPA's reviewed 4 staff records. LPA's reviewed 4 resident P&I records. LPA's reviewed 4 resident centrally stored records. LPA interviewed 2 staff.

Deficiencies cited during today's visit. This report was reviewed with S1 Ninfa Gozon and a copy of the signed report was provided. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S2 working in the facility without association. Appeal rights were provided.

End Of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 11:34 AM - It Cannot Be Edited


Created By: Marcela Yanez On 01/23/2025 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARKSIDE VILLAS I
FACILITY NUMBER: 435202731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above By not associating S2 to facility prior to working inside the facility. S1 stated S2 has been working at the facility since 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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ADM stated associated S2 during visit. ADM will send a letter of understanding regarding regulation. ADM stated he will review the staff roster for both facility that they are fingerprinted and associated. ADM stated he will send the Plan Of Correction to LPA by due date of 1/30/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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