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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 01/03/2024
Date Signed: 01/03/2024 06:11:53 PM


Document Has Been Signed on 01/03/2024 06:11 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: 13DATE:
01/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Cecilia Ganzon & Aurelia Renta, Administrator/LicenseeTIME COMPLETED:
04:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to this facility to follow up regarding a previous inspection visit of 10/10/23, where LPA requested facility have resident R1 medically assessed to determine ambulatory status.
Resident R1's Physician Report in file, dated, 6/15/2023 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 had requested facility to have R1 medically assessed with a medical report completed in full. LPA once again went over requirements for facility to submit paperwork to Community Licensing regarding a request for bedridden room review.

In addition LPA found staff present in the facility S1, who was fingerprinted but has not received proper clearance to the facility. LPA went over requirements and a civil penalty was assessed for $100.00 for staff S1.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 06:11 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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2024
Section Cited
CCR
87355(e)(1

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87355(e)(1)Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health & Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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Facility to send in a written plan that they understand regulation and how they will meet it. Facility understands S1 may not be inside the facility or around any residents until proper clearance is received. POC due date 1/4/2024
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This requirement was not met as evidenced by: LPA found staff S1 who was fingerprinted but has not received clearance. S1 was in the facility today. This is an immediate risk to the Health & Safety of residents in care.
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Facility was issued a $100.00 civil penalty for failure to have proper clearance prior to working, residing or volunteering in a facility.
Type B
01/22/2024
Section Cited
CCR87458(c)

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87458(c) Medical Assessment (c)The licensee shall obtain an updated medical assessment when required by the Department. This requirement was not met, As evidenced by:
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Facility agrees obtain a current and fully completed Medical assessment for resident R1.
Facility to send in written plan on how facility will meet this requirement and stay in compliance.
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On 10/10/2023 LPA conducted a facility visit and requested facility to obtain a medical assessment, fully completed for R1 and as of today 1/3/2024 the facility failed to comply with needed request. This is a potential risk to the health & Safety of residents in care.
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POC due date 1/22/2024
attention LPA A Canela.
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: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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