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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 01/14/2024
Date Signed: 01/14/2024 02:23:09 PM


Document Has Been Signed on 01/14/2024 02:23 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
SANTA ROSA RO, 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) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 13DATE:
01/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Cecilia GanzonTIME COMPLETED:
02:40 PM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit. Administrator arrived during visit. LPA observed three staff on duty.

This building has two floors. The first floor are for residents and the second floor are for staff. LPA toured both inside and outside of the facility. All exits have audio alerts on the doors.

Four resident files were reviewed
Staff files were reviewed. LPA observed that annual staff training appears to be due starting this month through March and reminded administrator to work on annual staff training. Emergency drills are conducted quarterly.

The follow was observed and cited during today's visit:
-The backdoor of the building had a small metal rod that was stuck into the frame to the door on the bottom right side of the door frame that prevented the door from opening. This is a violation because it prevents the residents from leaving the facility. The caregiver removed the small metal rod and was instructed by LPA that it cannot be used to prevent the door from being opened. Only locks approved by the fire inspector are allowed on doors.
-A gardening machete was found in the backyard on a bench. This was accessible to residents. It was removed and locked in a shed during visit.
-There are two storage sheds in the backyard. One stored chairs and other facility items and is where the gardening machete was place and the other stored paint and other items. Both were found with no locks on them. This poses an immediate hazard to residents. LPA was shown that locks were found and placed on the doors for the sheds during visit.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946
VISIT DATE: 01/14/2024
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The following shall be updated and submitted to Community Care Licensing by 02/10/2024:
-LIC 500 facility personnel or staff schedule
-a copy of current liability insurance
-LIC 308 designation of administrative responsibility.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/14/2024 02:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because the back door was held closed with a small metal rod that was stuck into the door through the door frame on the bottom right side which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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It was removed during visit and Administrator stated she shall ensure the door is not held closed with something not approved by the fire department
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because LPA observed a gardening machete found on a bench in the backyard and two sheds with no locks on them that store paint and other items which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Locks were found for the sheds and placed on the doors during visit and the gardening machete was placed in one of the sheds. Administrator stated she shall ensure the sheds are locked when not in use by the staff.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2024
LIC809 (FAS) - (06/04)
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