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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 02/17/2021
Date Signed: 02/19/2021 12:11:54 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:
486803946
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LNTELEPHONE:
(707) 246-2754
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
02/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cecilia Ganzon, Aurelia Renta, Emilio ManioTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) A. Canela, made contact, via tele-visit, on 2/17/2021 at approximately 1:00PM, to conduct this Prelicensing inspection due to a change in ownership application that was received. LPA met with Applicants Cecilia Ganzon, Aurelia Renta and House manager Emilio Manio. Due to COVID – 19 precautions, a facility physical visit was not able to be conducted at this time. The facility received a fire clearance approval on 12/14/2020 by the Vallejo Fire Department for 17 non-ambulatory residents, no approval for bedridden residents.

On February 5, 2021 LPA conducted a virtual meeting with applicants and discussed this new Change in Ownership Application for Parkside Manor, # 486803946 that was submitted due to Application changes of Parkside Manor #480110389 that required a new license. Prior to this application and prelicensing inspection, the facility Parkside Manor #480110389 was placed on Non-Compliance plan for two years, on November 5, 2020 by the Department and was notified, it would be subject to increased quarterly monitoring to ensure compliance. Failure to comply with the terms and conditions of the compliance plan may result in administrative action.
The applicants, Cecilia Ganzon and Aurelia Renta understand, that upon licensure of this facility, Parkside Manor, # 486803946, the Non-Compliance plan will carry over to this new facility.

This two-story facility is located at 50 Cadloni Lane Vallejo and it has a total of 9 rooms and 3 bathrooms in the first level of the home that will be used for residents. The second level of the home is off limits with a gate at the bottom of the stairs and will be used by staff only. LPA observed a small table at the entrance of the home with hand sanitizer, masks, sign in book, thermometer and Covid-19 guidance postings. LPA observed all staff wearing a face mask.

Continue report see LIC9099-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946
VISIT DATE: 02/17/2021
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Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times. LPA observed all exits and walkways to be unobstructed. Required postings such as Complaint poster, Rights to resident councils, and client's rights were observed. Toxin are in locked cabinets in laundry room. Medications are centrally stored and observed locked. Sharps and knives are in the kitchen inaccessible to residents in care. Facility maintains the kitchen locked and understands snacks and fruits should be available or provided to residents in between meals. LPA observed adequate food supply per current census. Extra linens and hygiene supplies should be available for residents in care. Resident rooms were furnished per regulation. Grab bars and non-slip mats were observed in bathrooms. Facility tested all 9 smoke detector alarms in resident rooms and one in the hallway, which were found to be operational. Two fire extinguishers were observed charged and serviced on 11/5/2020. Water temperature was tested by the administrator and found to be 110.8 and within the required regulation of 105-120 degrees f. Facility has auditory alarms in exit doors and understands alarms should always be functional as the facility serves residents with Dementia and exiting may present a hazard. LPA observed residents’ rooms have call buttons and facility has also placed some call bells to assist residents with Dementia that may not be able to utilize the call button system. Facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall operate from each residents unit and transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

Component III Orientation was previously completed with Administrator.

LPA will notify CAB analyst unit of a completed pre-licensing inspection and submit pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC809 (FAS) - (06/04)
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