486803946-5-21-2021-21-AS-ACAA-C392KY-20210521172842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 05/19/2021
Date Signed: 05/21/2021 05:28:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	PARKSIDE MANOR		FACILITY NUMBER:	486803946
ADMINISTRATOR:	GANZON, CECILIA		FACILITY TYPE:	740
ADDRESS:	50 CADLONI LN		TELEPHONE:	(707) 246-2754
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	17	CENSUS:	DATE:	05/19/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	12:03 PM
MET WITH:			TIME COMPLETED:	04:04 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 conducted a case management- Legal/Non-compliance inspection, on 5/19/2021, at approximately 10:30 AM. LPA met with Licensee, Cecilia Ganzon. This inspection is being completed to ensure compliance with Non-Compliance Conference dated 11/5/2020. LPA toured the facility with the facility Administrator and the following was observed: All staff working today were observed wearing mouth coverings. There is an entrance table with PPE supplies and staff screened LPA upon arrival. LPA tested the water temperature in 3 bathrooms and all were within the required regulation of 105-120 degrees F. First bathroom tested at 117.5, second bathroom tested at 116.5 and the third bathroom tested at 116.7; all three bathrooms are located in the hallway and used by residents. 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 the facility remains free of odors from incontinence. Non-compliance plan also addressed complinace with auditory alarms, maintenace and operation and staff required yearly training. During inspection of auditory alarms of the facility, LPA found 3 out of 8 doors with the auditory alarm not operational during inspection. The alarm on the rear exit of the facility had been turned off. Facility staff explained, residents may have turned it off when they went to the outside patio. 2 resident rooms were also found with the auditory alarm not working or turned off. Non-compliance plan requested facility to ensure auditory alarms are operational as the facility serves residents with Dementia diagnoses. LPA went over facilities Maintenance & Operation and found areas in the backyard patio and decking that will need attention and corrected. Some of the wood is beginning to rot and they may be a potential hazard for residents in care, facility shall be in good repair at all times in accordance with regulation. See LIC9099-C for continued report

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARKSIDE MANOR	FACILITY NUMBER: 486803946
	VISIT DATE: 05/19/2021

NARRATIVE

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LPA reviewed staff training records and found all of the six staff working today, to have the required yearly training, including current proof of CPR/First aid.

LPA discussed facility alert system and/or hand held bells for residents to use when they need assistance. LPA also requested facility to submit additional physician paperwork regarding resident R1's ambulatory status. Reports to be submitted to LPA canela by 5/23/21 for review.

LPA consulted facility regarding regarding

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights and report will be emailed today to facility, due to technical issues.

See 809-D for deficiencies cited

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARKSIDE MANOR	FACILITY NUMBER: 486803946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/20/2021 Section Cited	1 2 3 4 5 6 7	87705(j) Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by todays facility inspection with licensee. There were 3 auditory alarms not operational or turned on and there are residents with Dementia. This is an immediate risk to the health and safety of residents in care	8 9 10 11 12 13 14	attention LPA A. Canela
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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