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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:03:48 PM


Document Has Been Signed on 07/27/2023 02:03 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: 12DATE:
07/27/2023
TYPE OF VISIT:ACase Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Aurelia Renta, Co-licensee/Office ManagerTIME COMPLETED:
01:30 PM
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On July 27, 2023, Licensing Program Analyst (LPA) A. Canela conducted an unannounced case management visit and met with Aurelia Renta, co-licensee. The reason of the visit is to deliver and issue an enhanced civil penalty (ECP) that was under review. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. LPA arrived at the facility to issue ECP under facilities previous license, Parkside Manor #480110389.

During todays visit there were 12 residents living in the home. The home was at a comfortable temperature.

No deficiencies cited under this license.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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