216800418-1-26-2023-21-AS-DTOA-CNFULL-20230126144054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800418
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:41:01 PM

Document Has Been Signed on 01/26/2023 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:	BROWN HOUSE		FACILITY NUMBER:	216800418
ADMINISTRATOR:	ANTYON LIGGINS		FACILITY TYPE:	735
ADDRESS:	36 BROWN DRIVE		TELEPHONE:	(415) 892-8972
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 6		CENSUS: 5	DATE:	01/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Antyon Liggins, Administrator		TIME COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/26/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Antyon Liggins. The facility currently provides care for 5 clients 1 of which was attending day program at the time of visit. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found throughout the facility and to be last charged on 6/15/2022 at the time of the visit. Smoke and carbon monoxide detectors were located on both levels of the facility, inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file. Toxins are stored in a locked cabinet located in the dinning room and maintenance closet. Sharps were observed to be kept locked in a designated drawer located in the kitchen. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides additional hygiene product to clients when requested and located in upstairs hallway closet. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets and found to be secured. LPA measured water at faucets accessible to clients which measured between 106.0 and 107.4 degrees F which is within Title 22 regulations between 105 and 120 degrees F. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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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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: BROWN HOUSE	FACILITY NUMBER: 216800418
	VISIT DATE: 01/26/2023

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During the inspection LPA observed the following items in need of repair:
- Sliding screen door leading to backyard
- Closet door in client (C1's) bedroom
- Paint damage in upstairs restroom

LPA Tobola issued Technical Violation. Administrator agrees to send photos for proof of corrections to CCLD by POC due date 2/9/2023.

Antyon Liggins's Administrator Certification 6008072735 expires on 8/15/2023.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/9/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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