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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802077
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:58:04 PM

Document Has Been Signed on 03/20/2025 01:58 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:
03/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Janet Kirby, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On March 20, 2025 Licensing Program Analyst (LPA) Hansen met with Licensee for an unannounced inspection to follow up on a substantiated complaint allegation; complaint number 21-AS-20240119085541.  

On April 30, 2024, the Department concluded an investigation which allege facility failed to seek medical attention after change of condition.

The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 85075.4(c) Observation of the Client.

At the time of the complaint visit on April 30, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1548(f)(1)(A).

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Penal Code section 243 defines serious bodily injury as a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. This is evidenced by the facility failing to seek timely medical attention for resident that resulted in resident’s hospitalization for 5 days.


Today, March 20, 2025 the Department is issuing a civil penalty per Health and Safety Code §1548(f)(1)(A) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 as previously issued on April 30, 2024, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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