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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 02/14/2025
Date Signed: 02/14/2025 05:36:24 PM

Document Has Been Signed on 02/14/2025 05:36 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/
DIRECTOR:		GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LNTELEPHONE:
(707) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 17CENSUS: 13DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:51 PM
MET WITH:Aurelia Renta, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:28 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with licensee/administrator Cecilia Ganzon and Aurelia Renta.

This facility has 2 levels, the upper level is used for staff and a gate on the bottom of the stairs prevents access to residents. LPA toured facility and grounds and observed all required signs posted in common areas. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Kitchen area is gated and residents do not have access to any sharp objects. Fire Extinguishers were fully charged, and have proof of service on 2/13/2025. Smoke detectors and carbon monoxide detectors are operational. Fire drills are conducted and the last one was documented on 1/5/2025. Water temperature in the resident bathroom was tested and found to be within the required temperature regulation of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars. Residents have call bells to alert staff if needed.

Resident and staff files are located and locked in cabinets in office area. LPA reviewed resident files and were found complete and organized. Staff files were reviewed and had proof of training and CPR/1st aid expire on 2026.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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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
VISIT DATE: 02/14/2025
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Administrator certificate for Cecilia Ganzon #7034418740 is active and expires 7/28/2026.

During todays visit LPA observed residents watching television in the living room, some residents seating in the dining area and conversing and other residents in their rooms, sleeping or doing activities such as puzzles. Staff were also observed assisting residents and engaging with them.

Licensee/Administrator to submit the below documents to LPA by 3/10/2025.



· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-
Copy of Administrator Certificate



No deficiencies cited during todays inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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