216800418-6-8-2023-21-AS-CFES-CSLR57-20230608124240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800418
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:42:43 PM

Document Has Been Signed on 06/08/2023 12:42 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:	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:	06/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Antyon Liggins		TIME COMPLETED:	12:45 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	At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Staff Member, Carla Cadillo. Assistant Director of Program Operations, Holly Skidmore, arrived at approximately 10:00AM. Administrator, Antyon Liggins, arrived later during visit at approximately 10:45AM. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1/Incident Report 2/SOC-341: CCL received two incident reports on 04/07/2023. Incident reports were regarding Client 1 (C1) and Client 2 (C2) and the physical altercation that occurred between them on 04/03/2023. Facility also submitted an SOC-341 on 04/07/2023 regarding the incident. Review of the reports state that C1 was upset that housemates were coughing and kicked C2. C1 continued to escalate their behaviors. Staff members intervened and tried to redirect both clients. C1 then punched C2 in the face resulting in minor injuries. C2 was taken to the hospital to be evaluated. Administrator met with C1 to discuss the incident. Facility scheduled an appointment with C1's psychiatrist to review their medication. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 04/28/2023. Report stated that C1 was at a Physician's appointment where it was discovered that C1 had self-harmed themselves. Facility contacted C1's psychiatrist for an appointment. Facility has also provided C1 with alternative coping strategies, and has contacted C1's behaviorist to review their support plan. Facility made all appropriate notifications per regulation. Incident Report 4/Incident Report 5/SOC-341: CCL received two incident reports on 05/26/2023. Incident reports were regarding C1 and C2 and the physical altercation that occurred between them 05/25/2023. Facility also submitted an SOC-341 on 05/26/2023 regarding the incident. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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: 06/08/2023

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Continued from LIC809

Review of reports stated that C2 refused their shower and became agitated. C1 attempted to convince C2 to take their shower. Staff then heard a physical altercation between C1 and C2 where C1 punched C2 multiple times. Staff were able to separate the clients and de-escalate the situation. C2 was taken to the hospital to be evaluated. Facility made all appropriate notifications per regulation.

LPA discussed C1 and C2 with Administrator and Assistant Director of Program Operations. LPA was informed that C1 is new to the facility and is going through an adjustment period. They have also had a change in medication. As of today, 06/08/2023, the Facility has been in communication with C1's Responsible Party, Psychiatrist, Psychologist, Primary Care Physician, and Behaviorist to discuss C1's behaviors, coping strategies, and concerns. Facility has conducted a review of C1's medications and has ensured that an updated behavioral support plan and safety plan is in place. Facility has also increased staff supervision, and has ensured that all staff have the appropriate training for C1 and C2. Per conversation with Administrator and Assistant Director of Program Operations, C2 has been observed to have healed well from the physical altercations. Facility has continued to communicate with C2 and their Responsible Party to provide appropriate care needs. C2 and their Responsible Party have decided to relocate to a facility that is closer to family.

LPA conducted a walk though of the facility. LPA observed a hole in the wall located in the facility's dining room. Per conversation with Administrator, C1 had punched the wall on 05/25/2023. Facility submitted a request for it to be fixed, and it is expected to completed by 06/16/2023. Facility to send in a picture of fixed wall to CCL when completed.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) 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: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

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