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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:47:47 AM


Document Has Been Signed on 05/04/2022 11:47 AM - It Cannot Be Edited

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 MANORFACILITY NUMBER:
486803946
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LNTELEPHONE:
(707) 246-2754
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
05/04/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Cecilia Ganzon, Licensee/AdministratorTIME COMPLETED:
11:20 AM
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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 the Non-Compliance Conference dated, 11/5/2020. LPA met with Licensee/ Administrator, Cecilia Ganzon, and explained the reason of the visit.

LPA toured the facility with the facility Administrator and the following was observed: There are currently 14 residents living in the home, and facility is licensed for a capacity of 17 residents with a Hospice Waiver approval for 4 of the residents, all non-ambulatory and no approval for bedridden. 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 plenty of PPE available for staff and resident use. Staff follow indoor visitation requirement of verifying/tracking COVID-19 vaccination or a negative COVID test for non essential visitors.

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 it remains free of odors from incontinence. Auditory alarms were observed functional during this visit.
The facility was observed clean, free of odors with all exits free from obstruction. The front door is able to properly open and the side gates were observed not locked, facility is following regulation.


No citations issued during today's inspection.

Exit interview conducted with Administrator, and report was provided
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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