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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201009
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:48:39 PM

Document Has Been Signed on 02/17/2023 03:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BROWNELL CARE HOME IIFACILITY NUMBER:
435201009
ADMINISTRATOR:BROWNELL, MYRNAFACILITY TYPE:
735
ADDRESS:2019 SHELLBACK PLACETELEPHONE:
(408) 259-2969
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:BROWNELL, MYRNATIME COMPLETED:
04:00 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
Licensing Analyst Program (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Mryna Brownell and lead staff, Sherwin Magallanes.

During visit, LPA toured the facility with lead staff to include living room, dining room, kitchen, bedrooms, bathrooms, and backyard. LPA did not observe staff wearing a face mask.

Facility has a designated entry point for sign-in and temperature check for all visitors. Hand sanitizer made available at entry and throughout the facility. LPA observed an outdated visitation policy from year 2020 posted at the front entrance. LPA advised to remove the sign and post updated visitation guidelines based on the recent Provider Information Notices (PINs). LPA observed facility's Personal Protective Equipment (PPE) supplies and did not observe the facility to have surgical masks and enough gloves. ADM verbally states the staff are trained on infection control, but facility did not physically have the training record or infection control plan on-site. LPA advised facility to ensure training documents and infection control plan are presentable at the facility at all times. Facility staff are not N95 fit tested. LPA verbally provided resources to complete N95 fit-testing. LPA observed posters to include but not limited to, feeling ill, symptoms of COVID-19, and keep facility clean.

LPA observed the sliding door in a resident's room was difficult to slide open and close. LPA observed a live-in staff (S1) was not associated to the facility's roster. LPA confirmed S1 is fingerprint cleared.

The following documents were requested to send to the Department by Tuesday, 02/21/23: LIC500 and LIC610D.

A deficiency were cited per California Code of Regulations, Title 22. See LIC809D and LIC421BG. Advisory notes provided. This report was reviewed with Administrator, Myrna Brownell and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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 9
Document Has Been Signed on 02/17/2023 03:48 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/17/2023 at 03:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROWNELL CARE HOME II
FACILITY NUMBER: 435201009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) ... This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not transferring a live-in staff prior to working and residing at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2023
Plan of Correction
1
2
3
4
Licensee filled out the LIC9182 during visit and will fax the documents to the Department by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 9