486803946-2-11-2022-21-AS-ACAA-CBK32S-20220211165222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 02/11/2022
Date Signed: 02/11/2022 04:54:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

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: 13	DATE:	02/11/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	11:03 AM
MET WITH:	Cecilia Ganzon, Administrator/co-licensee		TIME COMPLETED:	03:49 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. The facility was toured and LPA 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. The facility has several sections with PPE tables throughout the facility hallways. 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. Staff follow indoor visitation requirement of verifying/tracking COVID-19 vaccination or a negative COVID test for visitors. Upon arrival to the facility, staff S1 got to the door and turned around to run and get a key to open the door. LPA observed that facility staff had to use a key to open the entry door key lock, so the door could open. LPA explained to staff, this was a zero tolerance violation and for the safety of the residents and staff, the door should be able to open incase of a fire. LPA toured the side backyard gates and observed the right side gate would not open, the latch is on the wrong side of the door and the latch was tangled and tied with string to prevent the door from opening from the backyard. This facility does not have approval from the Fire department or CCL for a locked perimeter. Continue report and citations, see LIC809-C and LIC809-D

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PARKSIDE MANOR	FACILITY NUMBER: 486803946
	VISIT DATE: 02/11/2022

NARRATIVE

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It was disclosed to LPA by staff S1, the front door was key locked because they were getting ready for lunch and wanted to make sure no one got out. LPA went over the responsibility of facility staff to provide care and supervision at all times and that locking a door with a key as a form of supervision is not appropriate as it violates Fire safety protocols to ensure the safety of residents and staff exiting a facility incase of a fire.
Immediate Civil Penalty assessed in the amount of $500 during today's inspection for Zero Tolerance violation ; 87203 Fire Safety.

In addition, LPA went over Death report the facility submitted for resident R1.
It was disclosed resident R1 was loosing their appetite and refusing meals on 1/20/22 and notified R1s physician. R1's physician made a visit to the facility on 1/26/2022 and saw R1. R1 was sent out to hospital on 2/1/2022 by facility and R1 was noted to may have suffered a stroke. R1 was placed on Hospice comfort care on 2/3/2022 and discharged to the facility/home on 2/4/2022. R1 expired on 2/5/2022 and a Death report was submitted to CCL by the facility. In review of records and Hospice plan, it was observed R1 returned to the facility on Hospice but was bed bound. Facility explained they understood from hospital it was Hospice and comfort care and understand they may not accept any bedridden residents unless they have approval to have bedridden residents by the Fire department. Facility disclosed they were not allowed to see R1 at the hospital when being discharged but understand now, they need to be in communication with the hospital in regards to the needs of the resident to ensure the facility can meet those needs. LPA consulted and answered administrators questions regarding observance of a resident, documentation, resident needs, facility and staff responsibility.

Per California Code of Regulations, (Title 22, Division 6), The following deficiency for key locked front door and locked perimeter gate was observed, and are being cited on the attached LIC 809-D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator, this report and Appeal Rights will be emailed to facility today, 2/10/22.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PARKSIDE MANOR	FACILITY NUMBER: 486803946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/12/2022 Section Cited	1 2 3 4 5 6 7	87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on LPA's observation & interviews, the Facility did not ensure the regulation above when they key locked front door and by locking 1 of 2 perimeter gates with tied string on latch. This is an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	(POC) to Community Care Licensing attention LPA Araceli Canela by POC due date 2/12/2022 **Immediate Civil Penalty assessed in the amount of $500.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

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