<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 11/22/2021
Date Signed: 11/23/2021 11:24:43 AM

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: 13DATE:
11/22/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Cecilia GanzonTIME COMPLETED:
02:29 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Canela arrived at this facility, unannounced, to conduct a Case Management Legal/Non-Compliance follow up visit. This inspection is being completed to ensure compliance with a Non-Compliance Conference dated 11/5/2020. LPA met with Licensee/ Administrator Cecilia Ganzon, and Christine Daquioag toured the facility, made observations and reviewed records.

LPA toured the facility with the facility Administrator and the following was observed: Staff working today were observed wearing mouth coverings. There is an entrance table with PPE supplies and staff screened LPA upon arrival. Water temperature in 2 bathrooms were within the required regulation of 105-120 degrees F. LPA went in all 9 resident bedrooms of the first level of the home and resident rooms were found free of odors as requested in non-compliance plan by CCL for the facility to ensure the facility remains free of odors from incontinence. Auditory alarms were observed functional during this visit. The deck in the rear and sides of the building was in good repair. First aid and CPR training was current in 5 of 5 staff files reviewed.

LPA consulted facility regarding sliding door in room 4 that was getting stuck, Administrator called maintenance staff to service the door, so the door opens easily. Staff follow indoor visitation requirement of verifying/tracking COVID-19 vaccination or a negative COVID test within 72 hours for visitors.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1