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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:38:23 PM


Document Has Been Signed on 10/10/2023 04:38 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:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Cecilia Ganzon, AdministratorTIME COMPLETED:
04:37 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to this facility regarding another matter and observed the facility has replaced the flooring of the facility and informed LPA they will also be replacing or doing repairs to the backyard deck.

LPA reminded facility, any work on the facility must be reported to Community Care Licensing(CCL) in writing prior to starting. The notification should include the type of work being performed, when it will start and be completed, permit requirements and how the residents of the home will be protected and not be affected by the work being done.

LPA also requested facility to remove stored items covered by a tarp from the side of the home, failure to remove may result in citations being issued. LPA also went over resident R1 who has a Physician Report in file, dated, 6/15/2023 but report does not indicate R1s ambulatory status. Prior Physician report for R1 dated 2/23/2022 indicates R1 as Non-ambulatory, but there is a question regarding R1s current ambulatory status and LPA requested facility to have the 6/15/2023 medical report completed in full. Facility understands, they do not have approval for bedridden residents at this time. LPA went over requirements and items needed for the facility to request approval for bedridden residents from the fire department and CCL

LPA consulted regarding vaccinations.
No citations issued during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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