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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110389
Report Date: 11/05/2020
Date Signed: 02/05/2021 01:32:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PARKSIDE MANORFACILITY NUMBER:
480110389
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LANETELEPHONE:
(707) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 15DATE:
11/05/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Cecilia GanzonTIME COMPLETED:
01:21 PM
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers and Licensing Program Analyst (LPA) Araceli Canela made contact on this date, via tele-visit, with Licensee/Administrator, Cecilia Ganzon, lead care staff, Emilio Manio & Aurelia Renta for the purpose of reviewing reports for Non-Compliance Conference. It is being conducted by tele-visit phone due to COVID - 19 precautions.

Verbal commitment from Licensee/Manager was received for Non-Compliance plan during conference.

Areas of concern and non-compliance were discussed. Items addressed in today’s meeting include but not limited to the areas below:
  • Recent substantiated complaint findings, Facility failed to seek timely medical attention for resident. Facility did not call 911 and resident was in the facility 2 days with a broken hip. Resident passed away 1 day after being admitted to the hospital, additionally resident came in to hospital with a Pneumonia, severe sepsis.
  • Care of Persons with Dementia - continued failure to have auditory devices working on doors.
  • Maintenance & Operation.
  • Managed Incontinence.
  • Personal Rights - Resident supervision.
  • Lack of Staff training.

Parties agreed on the two year compliance plan; refer to LIC 9111.
Facility was provided CCLD website: www.ccld.dss.ca.gov to review Self Assessment Guide, Pins and additional Resource Guides for Licensees.

This report was emailed to facility to obtain signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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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