496802077-4-22-2022-21-AS-SHAN-CDQUCN-20220422152812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802077
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:28:19 PM

Document Has Been Signed on 04/22/2022 03:28 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	KIRBY PARKSIDE		FACILITY NUMBER:	496802077
ADMINISTRATOR:	KIRBY, JANET		FACILITY TYPE:	735
ADDRESS:	3480 BANYAN STREET		TELEPHONE:	(707) 570-1548
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 3		CENSUS: 2	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Janet Kirby		TIME COMPLETED:	03:27 PM

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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Licensee/Administrator Janet Kirby for the visit. There is a total of 2 clients at the facility.

LPA initiated a tour of the facility at 2:05 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation and adequate lighting. Water temperature at faucets accessible to clients measured within regulation of 105 degrees to 120 degrees F. Extra hygiene products are kept in the cabinet in the bathroom. Extra Linens are stored in the cabinet in the hall closet. Cabinet located under the kitchen sink containing cleaning supplies was locked. Facility has two days of perishable and one week of non-perishable foods for current census.

Fire extinguisher was fully charged. Smoke detectors located throughout the facility were tested and operational along with carbon monoxide detector was tested and operational as well. Disaster Drills are conducted 2 times a year with the last being November 17, 2021.

Infection Controle:

Facility has submitted a mitigation program plan that was approved, 3/24/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. The facility has a sufficient supply of personal protective equipment (PPE) stored in kitchen pantry. All staff have been fully vaccinated and received their COVID booster shots.

Continued on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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: KIRBY PARKSIDE	FACILITY NUMBER: 496802077
	VISIT DATE: 04/22/2022

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LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

No deficiencies cited today.
Exit interview conducted with Licensee/Administrator Janet Kirby.

LPA requested additional updated forms to be sent to CCL by May 10, 2022:

LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Client Cash Resources
LIC 402 Surety Bond
LIC610 Emergency Disaster form

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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