486803946-8-10-2021-21-AS-KMOA-C7ALL7-20210928085036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803946
Report Date: 08/10/2021
Date Signed: 08/10/2021 12:58:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2021 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20210513124951

FACILITY NAME:	PARKSIDE MANOR		FACILITY NUMBER:	486803946
ADMINISTRATOR:	GANZON, CECILIA		FACILITY TYPE:	740
ADDRESS:	50 CADLONI LN		TELEPHONE:	(707) 246-2754
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	17	CENSUS: 14	DATE:	08/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cecelia Ganzon, Licensee/Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not ensure that resident was transported to a medical appointment.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/10/2021 at 9:45 am Licensing Program Analysts Chris Arnhold and Jill Nakagawa arrived unannounced to investigate the allegation that facility staff did not ensure that resident (R1) was transported to medical appointment.

Record review of the resident's Physician's Report (LIC602A) indicates that R1 is able to leave the facility unassisted, therefore the allegation is unfounded.

No citations issued due to this allegation.

Unfounded

Estimated Days of Completion:

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2