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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802077
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:11:50 PM

Document Has Been Signed on 04/30/2024 03:11 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 PARKSIDEFACILITY NUMBER:
496802077
ADMINISTRATOR/
DIRECTOR:		KIRBY, JANETFACILITY TYPE:
735
ADDRESS:3480 BANYAN STREETTELEPHONE:
(707) 570-1548
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 3CENSUS: 1DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Janet Kirby, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility delivering findings of a complaint investigation and conducted a case management. LPA met with Licensee/Administrator Janet Kirby. The purpose of this case management is to follow up on issues found during a complaint investigation.

On 1/23/2024 while opening complaint (21-AS-20240119085541) investigation, interview with Licensee revealed all client documents for (C1) were sent with them in the ambulance PM of 1/16/2024. Title 22 Regulation 80070(g) requires facilities to retain clients records for at least three (3) years following termination of service to the client.

The facility also did not report or submit required incident report (LIC624) to Licensing Agency, which per regulation was to be done within 7 days of following the incident occurrence. 80061(b)(1)(E).

Facility is being cited today for the above 2 violations.

The following deficiencies were observed (see LIC 809D) 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
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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Document Has Been Signed on 04/30/2024 03:11 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/30/2024 at 10:21 AM
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: 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 B
05/07/2024
Section Cited
CCR
80070(g)

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80070(g) Original client records or photographic reproductions shall be retained for at least three years following termination of service to the client. This requirement was not met as evidenced by:
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Licensee to review regulation and sign and date self certificate acknowledging understanding of regulation and submit to CCL by POC due date of 5/7/2024 .
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Based on interview conducted with Licensee, licensee did not retain client records for 3 years after termination of services. This poses a potential Safety risk to clients in care.
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Type B
05/07/2024
Section Cited
CCR80061(b)(1)(E)

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80061(b)(1)(E) Reporting Requirements. Reports are required for any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
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Licensee to ensure all incidents that threaten the safety of clients are reported to CCL per regulation. Licensee to review regulation 80061 and conduct training for all staff on reporting requirements.
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Based on records reviewed, Licensee failed to report C1 had a change in condition and was transported to hospital, to CCL per regulation. This poses a potential Safety risk to clients in care.
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And submit a signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted to CCL by POC date of 5/7/2024. Copy of regulation 80061 was left for Administrator.
Licensee to also submit SIR (LIC624) for incident that occurred with C1 on 1/16/2024 By POC due date of 5/7/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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