<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800460
Report Date: 01/09/2024
Date Signed: 01/10/2024 09:38:09 AM

Document Has Been Signed on 01/10/2024 09:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BROWN RESIDENTIAL HOMEFACILITY NUMBER:
331800460
ADMINISTRATOR:BYRON FLEMINGFACILITY TYPE:
735
ADDRESS:12442 FEATHER DRIVETELEPHONE:
(951) 735-0278
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 4DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sherry Brown- AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/09/23 at 10:45 AM, Licensing Program Analysts (LPAs) Melody Brown & Bianca Wolcott arrived unannounced to conduct the required comprehensive annual visit to the facility. LPAs met with Staff and met at facility & introduced themselves, and stated the purpose of the visit. Licensee/Administrator Sherry Brown arrived during the visit.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPAs
Brown & Wolcott completed a walk through of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPAs Brown & Wolcott observed two (2) clients. There are no obstructions to indoor & outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees F. LPAs Brown & Wolcott inspected client bedrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested 107 degrees F. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 01/10/2024 09:38 AM - It Cannot Be Edited


Created By: Bianca Wolcott On 01/09/2024 at 03:09 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in by not obtaining a criminal record clearance for Staff #4 prior to employment on 03/27/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee submitted LIC 508 per Guardian required documents to LPAs Brown & Wolcott during the visit. POC cleared.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in by not updating C1 medication adminstration record (MAR) when C1 medication was dispensed today, 1/09/24, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80075(b)(5)B), and submit proof of all staff training log to LPA Brown & Wolcott at POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 01/10/2024 09:38 AM - It Cannot Be Edited


Created By: Bianca Wolcott On 01/09/2024 at 03:09 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(G)3.d
Needs and Services Plan
d. Preexisting medical conditions or any physical disabilities or limitations that would place the person at greater risk during restraint or seclusion.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in by not completing the required Needs & Services Plan for C1, C2, C3, & C4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
1
2
3
4
Licensee completed Needs & Services Plan for C1, C2, C3, & C4 during the visit on 1/9/24. POC cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460
VISIT DATE: 01/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard. The outdoor pathway on the side of the facility was free of obstructions. During the tour of the facility, LPAs Brown & Wolcott observed shared backyard fence broke on one side with sharp nails showing, which poses a potential hazard to clients. Screen door going to outside of yard is tore on right side. Deficiencies will be issued for both shared fence & screen. Furthermore, during the tour of the facility LPAs Brown & Wolcott observed two (2) bottles of chemicals in the linen closet unlocked making it accessible to clients in care. Deficiency will be issued, Licensee/Adminstrator Brown removed the two (2) bottles of chemicals out the linen closet and locked them up during the visit.

Food Service: LPAs observed two (2) day(s) supply of perishable food and seven (7) day(s) of supply of non-perishables food and snacks. Dishes, cups and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 4 hours a day, 7 days a week.

Record Review: LPAs Brown & Wolcott, reviewed client files for Admission Agreements, Functional Capabilities, Pre-placement Appraisal, Needs and Services Plan and Physician Report (LIC602). LPAs Brown & Wolcott observed that C1, C2, C3 and C4 do not have the Needs and Services Plan, in their facility file. Deficiency will be issued. During the visit, Licensee/Administrator Brown completed the required Needs and Services Plan for C1, C2, C3 and C4. LPAs also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings and Tuberculosis (TB) Test result. Per LPAs Brown and Wolcott records review, Staff #4(S4) does not have Criminal Background in S4 file. Deficiency will be issued and civil penalty of $500.00 will be issued today, 1/9/24. LPA Brown reviewed C1,C2,C3, and C4 P&I records and LPAs Brown & Wolcott observed no issue. LPAs Brown & Wolcott reviewed C1 and C2 medications. LPAs Brown & Wolcott observed (C1) MAR was not signed, a deficiency will be issued.. Moreover, LPAs Brown & Wolcott observed that Staff #10 and Staff #11 have criminal background clearance but per records review, their criminal background clearance were not transferred to the facility prior to employment. Deficiency and civil penalty of $500.00 will be issued today, 1/9/24 per individual.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 01/10/2024 09:38 AM - It Cannot Be Edited


Created By: Bianca Wolcott On 01/09/2024 at 04:01 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(i)(2)
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f). or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring the criminal record clearance for Staff #10 (S10) and Staff #11 (S11) prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
1
2
3
4
Licensee submitted LIC 9182 for S10 & S11 to LPAs Brown & Wolcott during the visit on 1/9/24. POC cleared.
Type B
Section Cited
CCR
80087(a)
80087 Buildings & Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having the fence and the screen door of the facility in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
1
2
3
4
Licensee stated to repair the fence and make sure the sharp nails are removed and submit proof to LPAs Brown & Wolcott at POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 01/10/2024 09:38 AM - It Cannot Be Edited


Created By: Bianca Wolcott On 01/09/2024 at 04:20 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds- Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a dange if readly available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not locking the two (2) bottles of chemicals found in the linen closet making it accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee removed the two (2) bottles of chemicals found in the linen closet during the visit today, 1/9/24 and transferred to a locked cabinet. POC cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROWN RESIDENTIAL HOME
FACILITY NUMBER: 331800460
VISIT DATE: 01/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Deficiencies were cited during the visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102, LIC421BG and Appeal Rights were discussed and copies were provided to Licensee/Administrator Sherry Brown.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 10 of 10