216800418-12-20-2023-21-AS-HRUS-CYPVNL-20231220153519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800418
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:35:26 PM

Document Has Been Signed on 12/20/2023 03:35 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
SANTA ROSA RO, 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:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Kayla Hotchkiss, Manager of Program Operations, Syed Hashmi, Acting Administrator		TIME COMPLETED:	03:45 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 9:55AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and was greeted by staff. Manager of Program Operations, Kayla Hotchkiss, and Acting Administrator Syed Hashmi, arrived at a later time. LPA initiated a tour of the facility at approximately 10:15AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 124.5, 124.1,and 125.4 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation (see LIC809D). Extra hygiene products and linens were available. Additional cleaning supplies and disinfectants are stored in a locked closet which is inaccessible to clients in care. Facility has at least two days of perishable and one week of non-perishable foods which was stored per regulation and were of quality. Medications were centrally stored and locked. Emergency food and water supply are stored in downstairs office. Facility has a pool in the backyard that is fenced and inaccessible to clients in care. Fire extinguishers were last serviced May of 2023. Facility has Smoke and Carbon Monoxide detectors located throughout the facility that were tested and operational during visit. Most recent fire/disaster drill was conducted July 28, 2023 (see LIC809D). Per conversation with Manager of Program Operations, it is understood that drills must be conducted every 3 months as per regulation. Continued on LIC809C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROWN HOUSE	FACILITY NUMBER: 216800418
	VISIT DATE: 12/20/2023

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
26
27
28
29
30
31
32

Continued from LIC809

On 12/18/2023, LPA sent an email to Syed Hashmi regarding the administrator paperwork that is required for change of administrator. Community Care Licensing (CCL) has not yet received the required paperwork to begin processing the change of administrator. Per conversation with Manager of Program Operations, Syed Hashmi has completed everything and is waiting to get onto the pending administrator certificate list. All the paperwork LPA requested on 12/18/2023 is to be submitted to CCL on 12/22/2023.

Five client files were reviewed. Staff files were not available on site for LPA to review at the time of inspection. Director of Program Operations understands that these must be on site for licensing to review.

LPA could not finish the annual inspection at this time. LPA will return to continue the inspection at a later date and review client cash resources, staff files, and conduct interviews.

Facility to submit the following documents to CCL by 01/20/2024:

LIC 500 Personnel Report
LIC9020 Register of Clients
LIC308 Designation of Facility Responsibility
Plan of Operation/ Program Plan

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 12/20/2023 03:35 PM - It Cannot Be Edited

Created By: Helena Rummonds On 12/20/2023 at 02:51 PM

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: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 sinks accessible to clients in care delivering water above 120 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Licensee to submit self certification of water heater temperature turned down by POC due date of 12/21/2023. Licensee to submit hot water temperature log of all sinks accessible to clients with temperature within acceptable range of 105-120 degrees F to LPA by 12/27/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Helena Rummonds

LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/20/2023 03:35 PM - It Cannot Be Edited

Created By: Helena Rummonds On 12/20/2023 at 02:51 PM

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: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having disaster drills conducted since July of 2023 which poses a potential safety risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Licensee to provide proof of disaster drill being conducted by POC due date of 12/27/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Helena Rummonds

LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4