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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411363
Report Date: 02/27/2020
Date Signed: 02/27/2020 01:06:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BROWN, SENOVIAFACILITY NUMBER:
013411363
ADMINISTRATOR:BROWN, SENOVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 567-6188
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:12CENSUS: 4DATE:
02/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Senovia BrownTIME COMPLETED:
01:15 PM
NARRATIVE
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 LPAs Dayna Collier and Elimika Brown met with licensee Senovia Brown for a case management inspection as a result of receiving an unusual incident report. Present for the inspection were licensee, licensee's assistant Brenda, licensee's adult daughter Von Jewel and 4 children in care consisting of 2 infants and 2 preschoolers.
A review of staff records on 2/27/2020 indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions except Von Jewel Brown who resides in the home but does not have a criminal record clearance.

The attached type A deficiency is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by Licensee.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: BROWN, SENOVIA
FACILITY NUMBER: 013411363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2020
Section Cited

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102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement was not met as evidenced by record review and poses an immediate risk to children in care.
LICENSEE'S ADULT DAUGHTER VON JEWEL BROWN HAS MOVED INTO THE HOME WITHOUT A CRIMINAL RECORD CLEARANCE.
AN LIC 421BG FORM WAS GIVEN.
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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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2020
LIC809 (FAS) - (06/04)
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