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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202647
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:15:29 PM

Document Has Been Signed on 01/08/2025 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARKSIDE VILLA INCFACILITY NUMBER:
435202647
ADMINISTRATOR/
DIRECTOR:
FORONDA-CAYABYAB, MARIEFACILITY TYPE:
740
ADDRESS:300 S 22ND STTELEPHONE:
(408) 831-7411
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 15CENSUS: 14DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Lead Staff Ninfa GozonTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with lead staff Ninafa Gozon (S1). During the visit, LPA observed 3 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 4 restrooms and 8 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA observed a storage unit in the backyard, which is being used as storage.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degrees F, and hot water temperature was measured to range from 108-115 degrees F in resident bathrooms.

Fire extinguisher was serviced in April 22, 2024. The facility was equipped with smoke and carbon monoxide detectors were last tested in January 1, 2024. Staff S1 stated the facility has a scheduled sprinkler system inspection on January 19, 2025. S1 stated she would send LPA a copy of the report. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 23, 2024.

LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

No deficiencies cited during today's visit. This report was reviewed with Lead Staff Ninfa Gozon and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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