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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800418
Report Date: 01/02/2025
Date Signed: 01/02/2025 12:21:01 PM

Document Has Been Signed on 01/02/2025 12:21 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 HOUSEFACILITY NUMBER:
216800418
ADMINISTRATOR/
DIRECTOR:		ANTYON LIGGINSFACILITY TYPE:
735
ADDRESS:36 BROWN DRIVETELEPHONE:
(415) 892-8972
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Krysteena Brice, Program Manager
Yvette Morgan, Manager of Program Operations		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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01/02/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required.

At approximately 9:35am, LPA and Program Manager toured the building and grounds. The facility was found to be at a comfortable temperature and passageways were free from obstructions. Facility has a pool in the backyard that is fenced and inaccessible to clients in care. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 111.2 and 111.0 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in a locked drawer in the kitchen and in a locked pantry. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 4 client records. All records had the required documentation. Client cash resources were reviewed.

LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

LPA followed up on an incident report that was submitted to CCL on 11/25/2024. Incident Report states Client 1 (C1) was walking out of their room when their knees buckled causing C1 to fall. Staff called program manager to inform them about C1's fall and C1s foot and knee were swollen. Staff then took C1 to the emergency room where they took x-rays and facility was told C1 broke his foot in three different places. Facility made all appropriate notifications per regulation.

Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROWN HOUSE
FACILITY NUMBER: 216800418
VISIT DATE: 01/02/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC402- Surety Bond
Emergency Disaster Plan (review, update if needed)
Infection Control Plan (review, update if needed)

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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