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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800419
Report Date: 12/08/2021
Date Signed: 12/08/2021 12:10:27 PM

Document Has Been Signed on 12/08/2021 12:10 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HICKORY HOUSEFACILITY NUMBER:
216800419
ADMINISTRATOR:BROWN-STEWARD, LAKEDAFACILITY TYPE:
735
ADDRESS:426 HICKORY LANETELEPHONE:
(415) 472-7204
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Administrator, Lakeda Brown-StewardTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Hickory House for the purpose of conducting an unannounced Required 1 year inspection. LPA was greeted at the door by Administrator, Lakeda Brown-Steward. Administrator granted access into the facility.

LPA toured the facility with the Administrator at 11:25 AM. The facility was clean and well organized. Smoke; fire; carbon monoxide all current. All exits unobstructed. Hot water tested at 115 F degrees. Medication and hazardous materials locked and stored away. Fresh and non-perishable food in adequate supply. Sufficient linens and hygiene products available for the clients. Disaster drill log current. Fire extinguisher was found to be last charged in July 2021. First Aid kit was inspected and found to be sufficient at this time. There is a pool on premises that had five feet gate all around, locked and inaccessible to clients in care. No firearms were present in the home at the time of the inspection. Medications were found to be stored according to regulations and inaccessible to clients in care. Bathrooms and clients bedrooms clean and adequately furnished. Grounds free of any apparent hazards. Toxins are stored in a locked cabinet inside the facility garage. Dangerous items were stored inaccessible to clients. There were an ample supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with hand soap dispenser. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads on client’s beds as required by Title 22 Regulations

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE supplies. Staff have had all PPE training required and have had N95 Fit testing.

No deficiencies observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report signed and emailed to the Administrator, Lakeda Brown-Steward.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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