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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800419
Report Date: 03/05/2025
Date Signed: 03/05/2025 12:25:33 PM

Document Has Been Signed on 03/05/2025 12:25 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:
03/05/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Lakeda Brown, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At approximately 8:50am, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to conduct a Case Management - Annual Continuation visit and were greeted by staff Keith Barnes. Lakeda Brown, Administrator, arrived at approximately 10:00am. Upon arrival, LPAs were informed that there were five (5) clients in care with three (3) clients out of the facility attending Day Program.

At approximately 9:00am LPAs conducted a review of clients files and staff files, all required documentation present. Staff all had current CPR/First Aid and three (3) out of five (5) staff had water safety certificates.

At approximately 11:30am LPAs conducted a check of P&I cash resources. All records present and cash is reconciled.

At approximately 11:40am LPAs conducted a check of medication. All medication centrally stored and locked.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
LIC308- Designation of Responsibility
LIC400 - Affidavit Regarding Client Cash Resources
LIC402 - Surety Bond
LIC610D - Emergency Disaster Plan (updated)


No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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