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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 07/15/2024
Date Signed: 07/16/2024 09:59:20 AM


Document Has Been Signed on 07/16/2024 09:59 AM - 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) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Cecilia Ganzon and Aurelia RentaTIME COMPLETED:
04:08 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced regarding another matter and to conduct a Case Management visit and enquire about a possible eviction the facility may have issued to resident R1.
LPA went over information received regarding the eviction for R1 and eviction procedure requirements with both Aurelia Renta(S1) and Cecilia Ganzon (S2). S2 explained that they issued a 60 day eviction for R1 for a higher level of care due to R1 refusing medications and some care from staff.
In review of the 60 day eviction that was issued for R1, the eviction issued was not a legal eviction, meaning that it did not meet Licensing requirements.
LPA discussed information needed in the letter and documentation when submitting the eviction to CCL within 5 days for review and approval.

Facility will follow up with resident getting a new medical assessment and facility stated they recently met with R1's family to go over R1's care needs. Facility was advised that they will need to reissue the eviction in they wish to proceed. LPA also went over mandated reporter requirements and reporting requirements.
LPA provided regulation for eviction procedures 87224.

No citations issued at this time.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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