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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800418
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:23:03 AM

Document Has Been Signed on 07/06/2023 11:23 AM - 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:BROWN HOUSEFACILITY NUMBER:
216800418
ADMINISTRATOR:ANTYON LIGGINSFACILITY TYPE:
735
ADDRESS:36 BROWN DRIVETELEPHONE:
(415) 892-8972
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 4DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator/Program Manager Antyon LigginsTIME COMPLETED:
11:25 AM
NARRATIVE
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Assistant Program Manager, Ivan Arce. Administrator/Program Manager, Antyon Liggins, was available by telephone and arrived later during visit at approximately 10:45AM. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 07/05/2023. Report states that on 07/01/2023, Care Staff was assisting Client 1 (C1) with their medications. Client 2 (C2) reached over the Care Staff's shoulder grabbing and ingesting Client 1's medication. Care staff immediately notified the Program Manager and transported C2 to the hospital to be evaluated. C2 was observed to have no side effects and returned to the facility on the same day. Since returning, C2 has been observed to be at baseline and to be doing well. Facility made all appropriate notifications per regulation.

LPA and Program Manager discussed the incident and preventative measures. LPA was informed that C2's routine involves receiving their medication first so they can get ready for bed. However with this incident, C2 was not in the medication area. Therefore, Care Staff prepared C1's medication first instead, which triggered C2 to become impatient and grab C1's medications.
LPA was informed that Facility will be conducting an In-service Training which will review the following topics: Medication Training/Proper Technique and How to Navigate Clients with Behaviors and Triggers.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, LIC 811 (Confidential Names), Plan of Corrections, and Appeal Rights, discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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Document Has Been Signed on 07/06/2023 11:23 AM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/06/2023 at 10:08 AM
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: BROWN HOUSE
FACILITY NUMBER: 216800418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by: Based on incident report reviewed and interview conducted, the Licensee did not
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Licensee to submit certification that In-Service training on Medications will be conducted for all staff by POC due date of 07/07/2023. Licensee to submit a sign in sheet to CCL that includes the following: Date, Training Agenda, Name/Job Role, and Signatures by POC due date of 07/16/2023.
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comply with the section cited above. Licensee did not ensure that clients were assisted with their medication appropriately resulting in C2 ingesting C1’s medication in error. This poses an immediate health and safety risk to clients in care.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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