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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802077
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:01:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240119085541
FACILITY NAME:KIRBY PARKSIDEFACILITY NUMBER:
496802077
ADMINISTRATOR:KIRBY, JANETFACILITY TYPE:
735
ADDRESS:3480 BANYAN STREETTELEPHONE:
(707) 570-1548
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:3CENSUS: 1DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Janet Kirby, Licensee/Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility failed to seek medical attention after change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Janet Kirby, Licensee/Administrator.

Facility failed to seek medical attention after change of condition- Reporting party alleges they were informed that client (C1) had a decrease in ability to move up and down stairs for the last couple of months, needing assistance and on 1/12/2024 could no longer ambulate and facility still did not seek medical attention until evening of 1/16/2024. On 1/23/2024 LPA conducted interview with Licensee that revealed on Friday 1/12/2024 C1 came downstairs for breakfast and then went back to their bedroom upstairs. At approximately 11:30am when licensee/Administrator went to get C1 for lunch, observed C1 had soiled themselves and could not get up or change themself any longer. C1 is non-verbal and visually impaired. Licensee could not get C1 up either and had to contact designee to help move C1.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20240119085541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KIRBY PARKSIDE
FACILITY NUMBER: 496802077
VISIT DATE: 04/30/2024
NARRATIVE
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 Licensee indicated C1’s physician left area over two months ago and a new one has not been provided. C1’s symptoms continued through 1/16/2024 when licensee, at suggestion of Service Coordinator (SC), called 911 to take C1 to Hospital. C1 was admitted to the hospital on 1/18/2024 from symptoms of (stopped walking, standing on feet, & became incontinent in bed) from 1/12/2024 on. Primary diagnosis dehydration, secondary weakness with procedure due to esophagitis and findings of mid-size hiatal hernia and gallstones. Medical records indicate due to C1 laying in bed for extended periods of time could cause worsening to esophagitis.

Based on LPA’s interviews and Hospital medical records obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Failure to seek medical care resulted in violation causing injury to person in care $500


immediate civil penalty issued.

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240119085541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KIRBY PARKSIDE
FACILITY NUMBER: 496802077
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2024
Section Cited
CCR
85075.4(c)
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85075.4(c) Observation of the Client. (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.
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Facility to submit self certification that clients will be observed for any changes in conditions and will notify either client’s physician, other Dr. if PCP is unavailable, and authorized representative by POC date 5/1/24.
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This requirement isn't met as evidenced by: Based on interviews & records review facility staff didn't comply w/this section for 1of1 client which poses an immediate Health & safety & personal rights risk to clients in care. Client C1 had a significant change of condition and facility did not seek medical care timely waiting over 4 days.
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********$500 immediate civil penalty issued today for failure to seek medical care resulted in violation causing injury to person in care.

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240119085541

FACILITY NAME:KIRBY PARKSIDEFACILITY NUMBER:
496802077
ADMINISTRATOR:KIRBY, JANETFACILITY TYPE:
735
ADDRESS:3480 BANYAN STREETTELEPHONE:
(707) 570-1548
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:3CENSUS: 1DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Janet Kirby, Licensee/Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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2
3
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9
Facility did not inform responsible party of change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Janet Kirby, Licensee/Administrator.

Facility did not inform responsible party of change of condition - Reporting party alleges C1 had a change in condition and facility did not inform responsible party for over two months. LPA conducted interview with Licensee on 1/23/2024 who informed C1 had not shown signs of any decline prior to 1/12/2024. On 1/24/2024 LPA’s interview with C1’s service coordinator (SC) at North Bay Regional Center (NBRC) revealed on the evening of 1/12/2024 Licensee left a message on SC’s office phone regarding C1’s condition but SC did not get the message until 1/16/2024 due to Monday the 15th being a State Holiday. Based on LPAs interviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, facility did not inform responsible party of change of condition, did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4