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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800419
Report Date: 02/28/2025
Date Signed: 02/28/2025 03:16:12 PM

Document Has Been Signed on 02/28/2025 03:16 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/
DIRECTOR:		BROWN-STEWARD, LAKEDAFACILITY TYPE:
735
ADDRESS:426 HICKORY LANETELEPHONE:
(415) 472-7204
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Lakeda Brown, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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At approximately 2:20PM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to conduct a Required 1 Year visit and met with 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, LPAs were informed that there were 5 clients in care with 4 clients out of the facility attending Day Program.

At approximately 2:30PM, LPAs conducted a walk-through of the facility with Administrator. LPAs observed the following: The facility was found to be clean and at a comfortable temperature. 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. Emergency water supply was observed as well as emergency lighting and supplies. 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 within Title 22 regulations of 105 degree to 120 degrees Fahrenheit.

Carbon Dioxide and Smoke Detectors were tested and operational during visit. Fire extinguishers were observed charged and last serviced April 2024. Facility has a swimming pool that was observed to be locked. Construction was observed in the garage to create a new staff room and facility storage. Per conversation with Administrator, once the new structures have been completed facility will submit a new facility sketch to CCL with updated labels.

LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies cited during visit.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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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