<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 09/30/2022
Date Signed: 09/30/2022 04:29:08 PM


Document Has Been Signed on 09/30/2022 04:29 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
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: 14DATE:
09/30/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Cecilia GanzonTIME COMPLETED:
12:58 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Canela arrived at this facility, unannounced, to conduct a Case Management Legal/Non-Compliance follow up visit. This inspection is being completed to ensure compliance with the Non-Compliance Conference dated, 11/5/2020. LPA met with Licensee/ Administrator, Cecilia Ganzon, and Aurelia Renta and explained the reason of the visit.

LPA arrived at the facility and observed 3 residents sitting outside in the front area, with no staff present. The front area has tables, chairs and a covered area, but it is not gated. This area has a shared driveway, that is also used by private entity and the front leads two a main street. There are currently 13 residents living in the home and facility is licensed for a capacity of 17 residents with a Hospice Waiver approval for 4 of the residents, all non-ambulatory and no approval for bedridden. Staff working today were observed wearing mouth coverings. There is an entrance table with PPE supplies and staff screened LPA upon arrival. The facility has plenty of PPE available for staff and resident use. Water temperature in 2 bathrooms were within the required regulation of 105-120 degrees F. LPA went in all 9 resident bedrooms of the first level of the home and resident rooms were found free of odors as requested in non-compliance plan by CCL, for the facility to ensure it remains free of odors from incontinence. Auditory alarms were observed functional during this visit.
LPA went over facility requirement to have workable signal system in all resident rooms.

Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report.
Due to printer issues, this report was emailed to Administrator. Appeal Rights Provided
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/30/2022 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2022
Section Cited

1
2
3
4
5
6
7
1569.269(a)(6) Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met, as evidenced By:
8
9
10
11
12
13
14
LPA Canela observed 3 residents sitting outside in the front area, with no staff present. Area is not gated, R1 has Dementia diagnoses and all 3 residents are not able to leave the facility unassisted. This is an immediate risk to the health and Safety of residents in Care
8
9
10
11
12
13
14
Plan of Correction due 10/1/2022
Type B
10/07/2022
Section Cited

1
2
3
4
5
6
7
87303(i)(1)Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1)All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Alert staff
8
9
10
11
12
13
14
During todays visit LPA observed and went over the requirement for facility to have workable signal system in all residents rooms. This is a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2