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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 08/10/2021
Date Signed: 08/10/2021 12:56:51 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 MANORFACILITY NUMBER:
486803946
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LNTELEPHONE:
(707) 246-2754
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
08/10/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cecilia GanzonTIME COMPLETED:
11:30 AM
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At approximately 10:00AM, Licensing Program Analyst's (LPA's) Jill Nakagawa and Chris Arnhold arrived at this facility, unannounced, to conduct a Case Management Legal/Non-Compliance visit. LPA's met with Licensee/ Administrator Cecilia Ganzon, toured the facility, reviewed records and interviewed staff and residents. This inspection is being completed to ensure compliance with a Non-Compliance Conference dated 11/5/2020. LPA's observed 8 of 8 alert devices on exit doors were in working order. The deck in the rear and sides of the building was in good repair. LPA's reviewed the 5 on duty staff training records and found the required number of hours documented in each staff file. First aid and CPR training was current in 5 of 5 staff files reviewed.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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