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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 02:41:00 PM

Document Has Been Signed on 04/30/2024 02:41 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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Janet Kirby, Licensee/Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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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. There is currently 1 client in care at this adult residential facility.

LPA initiated a tour of the facility at 11:30 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client room was furnished per regulation with 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 4/11/2024. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was also tested and operational. Medication is centrally stored although at 12:08pm while touring facility Licensee was unable to locate key to medication drawer and found clients medications under unlocked role top of desk.(see LIC 809-D). While touring facility garage, LPA and licensee observed a 5 gallon bucket of paint next to the freezer accessible to clients (see LIC 809-D). Last disaster drill was conducted 9/18/2023, over 7 months ago (see TA LIC 9102).

At approximately 12:30 PM, LPA reviewed one client and one personnel record, which were all found to be well organized, thorough and contained the required documentation, Although Licensee was unable to provide First aid and CPR certification as required (see LIC 809-D). Client handles own P&I monies. Administrator’s Certificate for Janet Kirby #6002353735 expires 3/31/2025.

Continue on LIC 809-C
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 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/30/2024 at 01:46 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: KIRBY PARKSIDE
FACILITY NUMBER: 496802077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Licensee's observation and interview the licensee did not comply with the section cited above finding 1 out of 1 5 gallon bucket of paint in garage next to freezer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee/Administrator was asked to lock the item during the visit, which they did. Administrator to submit self certification they will comply with regulation 80087(g) and submit docuement to Community Care Licensing (CCL) to clear the citation by POC due date 05/14/2024
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Licensee's observation, the licensee did not comply with the section cited above in 1 out of 1 perscription of medication was found under role top of desk, not locked and not in centrilly stored medication cabinet key is missing) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Staff immediately removed medication bottle and locked away in top drawer of desk with key. Licensee to keep all medications locked away at all times to ensure health and safety of clients. Licensee will review the procedures in section 80075(k)(1) and submit self certification they will follow regulation going forward by POC due date of 5/14/2024.
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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Document Has Been Signed on 04/30/2024 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/30/2024 at 01:46 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: KIRBY PARKSIDE
FACILITY NUMBER: 496802077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA s interview with Licensee and record review, the licensee did not comply with the section cited above in 1 out of 1 facilty quarterly disaster drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Facility agrees to submit an emergency disaster log to CCLD by POC date 5/14/2024 along with LIC9098 Proof of Corrections form ensuring compliance moving forward.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview with Administrator, the licensee did not comply with the section cited above in 1 out of 1 evacuation chair was not obtained in this 2 story facility after LPA provided TA at last years Annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Facility agrees to obtain required evacuation chair for 2nd story in case of emergency and submit proof (receipt) to CCL by POC due date 5/14/2024 to clear citation.
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


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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: 04/30/2024
NARRATIVE
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LPA Hansen is requesting Licensee to update and submit the following documents by 5/30/2024 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Copy of Administrator Certificate


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
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/30/2024 02:41 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/30/2024 at 02:14 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: KIRBY PARKSIDE
FACILITY NUMBER: 496802077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on interview & record review the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Licensee informed other staff stopped working at facility approximately 3 weeks ago. Facility has 1 out of 1 caregiver that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care.
POC Due Date: 05/01/2024
Plan of Correction
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Licensee to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that staff have been CPR trained per regulation and that facility will maintain a staff on duty who has CPR training at all times by POC due date 5/1/2024 and submit copy of CPR/First Aid certification by 5/14/2024 to clear citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
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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