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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803946
Report Date: 02/10/2026
Date Signed: 02/10/2026 02:50:26 PM

Document Has Been Signed on 02/10/2026 02:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PARKSIDE MANORFACILITY NUMBER:
486803946
ADMINISTRATOR/
DIRECTOR:		GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LNTELEPHONE:
(707) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 17CENSUS: 11DATE:
02/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Aurelia Renta, Back Up AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 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
At approximately 9:15 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit. Administrator Cecilia Ganzon was not at the facility during the inspection. Parkside Manor is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a multi-level complex with residents living on the ground level. The upper level is staff quarters.. The facility has an approved fire clearance for seventeen (17) residents, sixteen (16) of whom may be non-ambulatory. One (1) resident may be bedridden. The facility has a Hospice Waiver for four (4) residents. Upon arrival, LPA was informed that there were eleven (11) residents in care and two (2) staff members on-site. At approximately 9:30 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:35 AM, LPA toured the facility. All exits were clear and unobstructed. All three (3) fire extinguishers were last serviced and tagged on 2/3/2026. The Vallejo Fire Department conducted a Fire & Life Safety Inspection on 11/20/2025 and found no violations. The facility was sufficiently lighted. LPA inspected six (6) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. In the kitchen LPA observed two (2) large containers of eggs that were not refrigerated. Facility staff stated they were not refrigerated for the past 24 hours. Eggs are required to be refrigerated. This deficiency will be cited. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills every six (6) months with the last disaster drill having been conducted on 1/1/2026. Regulations require disaster drills be held quarterly. This deficiency will be cited. Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946
VISIT DATE: 02/10/2026
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
26
27
28
29
30
31
32
...Continued from 809
The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 10:40 AM, LPA reviewed five (5) resident files. Four (4) of five (5) resident files (for residents R1, R2, R3 & R4) were observed not to have current appraisals. Per regulations, resident appraisals are to be completed with a change of condition or annually if there is no change of condition. This deficiency will be cited. LPA reviewed five (5) staff files. Five (5) of five (5) staff files (for staff members S1 through S5) were observed not to contain proof of annual training for 2025. Two (2) of five (5) staff files (for staff members S1 & S3) were observed to have expired First Aid certification. Two (2) of five (5) staff files (for staff members S4 & S5) were observed not to have a medical assessment and proof of a negative tuberculosis test. These deficiencies will be cited. LPA audited Medication for four (4) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Cecilia Ganzon’s Administrator Certification 7034418740 is current with an expiration date of 7/28/2026.
Aurelia Renta’s Administrator Certification 7007148740 is current with an expiration date of 1/5/2027.
LPA requested the following documents be submitted to Community Care Licensing by 3/10/2026:
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

LPA discussed the Departments Technical Support Program (TSP) with back-up Administrator Renta.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to back-up Administrator Renta. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/10/2026 02:50 PM - It Cannot Be Edited


Created By: Robert Frank On 02/10/2026 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in that two (2) of five (5) staff files (for staff members S4 & S5) were observed not to have a medical assessment and proof of a negative tuberculosis test in their personal files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee or Administrator will submit a valid medical assessment and proof of a negative tuberculosis test for staff members S4 & S5 to Community Care Licensing by POC due date of 3/10/2026

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/10/2026 02:50 PM - It Cannot Be Edited


Created By: Robert Frank On 02/10/2026 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in that five (5) of five (5) staff files (for staff members S1 through S5) were observed not to contain proof of annual training for 2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee or Administrator to provide proof that staff members S1, S2, S3, S4 and S5 have completed their annual training for 2025 to Community Care Licensing (CCL) by POC due date of 3/10/2026.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in that two (2) of five (5) staff files (for staff members S1 & S3) were observed to have expired First Aid certification. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
licensee or Administrator to submit proof that staff members S1 & S3 have been certified in First Aid Training to CCL by POC due date of 3/10/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/10/2026 02:50 PM - It Cannot Be Edited


Created By: Robert Frank On 02/10/2026 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above in that In the kitchen LPA observed two (2) large containers of eggs that were not refrigerated. Facility staff stated they were not refrigerated for the past 24 hours. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee or Administrator will submit proof of Food Service Training for all staff members to Community Care Licensing (CCL) by POC due date of 3/10/2026.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in that four (4) of five (5) resident files (for residents R1, R2, R3 & R4) were observed not to have current appraisals. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee or Administrator to submit to CCL completed and signed Appraisals for residents R1, R2, R3 & R4 to CCL by POC due date of 3/10/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 02/10/2026 02:50 PM - It Cannot Be Edited


Created By: Robert Frank On 02/10/2026 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 486803946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above in that the facility is only conducting Emergency Disaster Drills bi-annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee or Administrator to submit an LIC 9098 self certification that in the future Emergency Disaster Drills will be held quarterly to Community Care Licensing by POC due date of 3/10/2026.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
Page: 7 of 7