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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802077
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:42:11 PM

Document Has Been Signed on 03/05/2025 03:42 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:
03/05/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Janet Kirby, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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A Non-Compliance Conference was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Shannan Hansen, via Microsoft Teams NBRC, Katy Vanzant & Isabel Tron-Coso , Licensee, Janet Kirby, and staff, Lanette Stankas & staff Tyler Stankas.

This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency regarding to the operation of this facility including but not limited to: Complaint investigation that has been substantiated for Resident sustained injuries while in care and timely medical attention. Other concerns that have been observed during complaint investigation/case management visit are:



- Timely Medical Attention: Facility failed to seek timely medical attention.

- Reporting Requirements: Facility didn’t submit to CCL required unusual incident report when client had a change in condition and was transported to hospital.

- Retain Original Client Records: Facility sent all of clients records with ambulance instead of keeping a copy as required by regulation 80070(g) for 3 years after separation of client from facility.

The Regional Office will re-review progress made on Non-Compliance Plan of 2 years. The Regional Office has offered Technical Support Resources (TSP). Licensee accepted TSP resources.


While conducting NCC licensee informed there will be 2 new Administrator's (Lanette Stankas & Tyler Stankas) and will be undergoing a Change of Ownership.

The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20240119085541. Licensee was also informed that substantiated findings may result in administrative action.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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