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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800419
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:29:12 PM

Document Has Been Signed on 02/28/2024 03:29 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: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:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Lakeda Brown-StewardTIME COMPLETED:
03:35 PM
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At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and Administrator, Lakeda Brown-Steward. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 5 clients in care with 3 clients out of the facility attending Day Program. LPA was also informed that there were two staff members on-site.

At approximately 12:40PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:50PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 Client bedrooms, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were measured at 98.2F, 97.4F, and 96.7F (this deficiency has been cited, see LIC809D, Regulation 80088(e)(1)). Facility has a swimming pool that was observed to be locked. Per conversation with Administrator, staff have water safety certificates in the event clients want to go swimming.

At approximately 1:00PM, LPA reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. During medication review, LPA observed that one client had pre-poured medication (see technical violation, LIC9102, Regulation 80075(k)(5)). Per conversation with Administrator, client is able to store and administer their medications but at this time, facility is storing the medication for them. Review of client's 602 indicated that they are able to store and administer their own medication. LPA informed Administrator that facilities are unable to pre-pour medications. Administrator stated that they will assess client's ability to manage their own medications and if client is unable to manage their medication appropriately, client's physician's report will be updated to where facility manages the medication.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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: HICKORY HOUSE
FACILITY NUMBER: 216800419
VISIT DATE: 02/28/2024
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Continued from LIC809

P&I monies were documented, secure and not commingled. Administrator's Certificate for Lakeda Brown-Steward (6004745735) was current with an expiration date of 06/26/2025.

Fire extinguishers were last inspected May 2023. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in February 2024.



LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate when available

Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 03/28/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC809D, LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 03:29 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/28/2024 at 03:13 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: HICKORY HOUSE

FACILITY NUMBER: 216800419

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observations made, the Licensee did not comply with the section cited above. LPA observed that the sinks in the facility measured at 98.2F, 97.4F, and 96.7F. This poses a potential health, safety, and personal rights risk to clients in care.
POC Due Date: 03/09/2024
Plan of Correction
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Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day starting 02/29/2024. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date 03/09/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
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