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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 12:57:57 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: DATE:
08/10/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cecelia Ganzon, Administrator/LicenseeTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA)Chris Arnhold and Jill Nakagawa conducted an unannounced post-licensing inspection on 08/10/2021.

This two-story facility is located at 50 Cadloni Lane Vallejo and it has a total of 9 rooms and 3 bathrooms in the first level of the home, 2 bathrooms will be used for residents. The second level of the home is not accessible to residents , and will be used by staff only. LPAs observed a small table at the entrance of the home with hand sanitizer, masks, sign in book, thermometer and Covid-19 guidance postings. Grab bars and non-slip mats were observed in bathrooms. Two Carbon Monoxide Detectors were tested. Three fire extinguishers were observed charged and serviced on 11/5/2020. Facility has 8 functioning auditory alarms in exit doors and understands alarms should always be functional as the facility serves residents with Dementia and exiting may present a hazard. LPAs observed residents’ rooms have call buttons and facility has also placed some call bells to assist residents with Dementia that may not be able to utilize the call button system.

No citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
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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