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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802077
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:31:09 PM

Document Has Been Signed on 04/20/2023 02:31 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:KIRBY, JANETFACILITY TYPE:
735
ADDRESS:3480 BANYAN STREETTELEPHONE:
(707) 570-1548
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 3CENSUS: 2DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Janet Kirby, Licensee/AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Shannan Hansen, arrived unannounced to conduct an Annual Required Inspection of facility. LPA met with Licensee/Administrator, Janet Kirby.

LPA initiated a tour of the facility at 1:00 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 extinguishers were last inspected July 15, 2022. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was present. Medication is centrally stored and secure.

LPA initiated a file review of two resident files and two personnel files but were unable to complete. LPA was also unable to review medication log and will return at a later date to complete annual inspection.

No deficiencies cited during today's inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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