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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 06/20/2022
Date Signed: 06/21/2022 09:16:20 AM


Document Has Been Signed on 06/21/2022 09:16 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 13DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Cecilia Ganzon and Aurelia RentaTIME COMPLETED:
02:19 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Case Management Inspection and met with administrator, Cecilia Ganzon and Aurelia Renta. LPA conducted risk assessment with care staff at facility entrance. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on some incident report that were submitted to Community Care Licensing (CCL) by facility regarding R1 and R2. It was reported R1 was observed with loose bowel movement, R1 was sent to ER and discharged back to the facility. R1 has been doing well. Facility submitted an incident report for R2, who was showing weakness on 5/26/2022, and required additional assistance, eating, dressing. R1 was sent to ER and diagnosed with Kidney Failure, R1 was placed on Hospice and is doing well, and requires assistance with all ADLs

Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test.

LPA went over planned activities for residents.

Exit interview conducted with Aurelia Renta.

No deficiencies cited during today's inspection

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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