486803946-7-16-2024-21-AS-KMOA-D8BP82-20240820110446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803946
Report Date: 07/15/2024
Date Signed: 07/16/2024 09:48:05 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240529102118

FACILITY NAME:	PARKSIDE MANOR		FACILITY NUMBER:	486803946
ADMINISTRATOR:	GANZON, CECILIA		FACILITY TYPE:	740
ADDRESS:	50 CADLONI LN		TELEPHONE:	(707) 557-8991
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	17	CENSUS: 14	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Aurelia Renta and Cecilia Ganzon		TIME COMPLETED:	03:07 PM

ALLEGATION(S):

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Failure to seek timely medical resulting in death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Araceli Canela arrived at this facility unannounced, to deliver findings regarding the above allegation. LPA met with both licensees, Cecilia Ganzon & Aurelia Renta.

It was alleged facility failed to seek timely medical resulting in death of a resident. LPA requested & received records; including Community Care Licensing (CCL) Investigations Branch report.
Investigation included review of Vallejo Police Department report #24-5069, in which there was no indication of foul play and R1's death was due to natural causes. The Medic Ambulance Patient Care Report indicated R1 had a DO Not Resuscitate (DNR) form in file. Per R1's Certificate of death, R1's cause of death was noted as Dementia with Lewy Bodies with onset notes as years. There was no indication that facility staff failed to seek timely medical attention resulting in death.
Based on the information gathered, the above complaint allegation is UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
No citations issued.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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