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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201009
Report Date: 02/15/2024
Date Signed: 02/26/2024 04:55:30 PM

Document Has Been Signed on 02/26/2024 04:55 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: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Myrna BrownellTIME COMPLETED:
06:30 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 2/15/2024 Licensing Program Analyst (LPA) Mita Partoza, conducted a required Annual visit to the facility and met with administrator (ADM) Myrna Brownell, and House Manager Sherwin Magallanes and 1 staff member.

Current facility census count 6 residents. At the time of the visit all residents arrived from their day program.

During the visit, LPA toured the facility and inspected the living room, dining room, kitchen, 3 resident bedrooms, 2 bathrooms and 1 staff room, garage and the exterior perimeter.

During inspection the following were observed:

There is sufficient supply of food for 7 days non-perishable food and 2 days non-perishable food. Dented canned food (7 observed) Milk with best if used by 2/7/2024, and food that were recently bought, cut onions on the plate and were put inside a cabinet to right side of the sink. LPA observed opened cleaning detergent under the sink in an unlocked cabinet. LPA observed decaying fresh produce in the plastic bag and inside the box located at the converted patio also used as informal dining area.

The laundry area is located in the garage accessible to residents. Inside the garage LPA observed eggs that was not refrigerated, alcoholic beverage on the open shelf and the laundry detergent was left on the floor unlocked and other cleaning supplies left inside an open basket.

page 1 of 3
continued to LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 435201009
VISIT DATE: 02/15/2024
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
continued from page 1 of the LIC 809
Page 2 of 3

LPA observation continued from page 1

The resident's bathroom needs maintenance and cleaning. During the inspection, LPA asked staff (S1) the number of bathrooms used by residents. S1 stated one bathroom is used but if residents (R1 to R6) needs to go to the bathroom, the staff bathroom is available for them to use. LPA observed that staff bathroom has cleaning supplies under the sink in an unlocked cabinet.

The resident's bedroom has ample storage for resident's personal items. Bedroom 2 (middle bedroom) has a broken closet door. The 3rd bedroom at the end of the hallway has a broken smoke alarm. The smoke alarm going towards the staff bedroom is broken.

The water temperature in the bathroom was tested and measured at 126.5 degree Fahrenheit. The kitchen water temperature measured at 128.8 degree Fahrenheit

The living room area has a corner office desk used by the lead staff as stated by ADM. LPA observed unlocked resident medicines and opened bottle of perfumes that were unlocked in the entertainment center located in the living room behind the office desk chair used by the lead staff. The office table drawers were inspected and LPA observed 4 bubble packs of medication for two of the residents and not in a locked and secured area. There was open bottle of perfume on the side rolling drawer, lighters inside one of the table drawer used for office supplies.

LPA observed laundry supplies on the side exit/entry doorway to the garage, not locked and in the open. Trash bins were observed blocking the walkway to the outdoor gate. The sliding screen located at the informal dining room is broken and not easily accessible.

continued to page 3 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 435201009
VISIT DATE: 02/15/2024
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
continued from page 3 of 3
First aid kit was inspected and observed to be complete and ready for use.

LPA observed required personnel training for emergency is not up to date. Dates of training given was from year 2022 and list of staff receiving the training was not available.

Due to time constraint LPA will continue with the annual required inspection and the following deficiencies will be cited on a later date.

The following citations will be given at a later date.
  1. 80087(g)(1)(c)- Buildings and Grounds - Storage areas for disinfectants, cleaning solutions, and poisons shall be locked.
  2. 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
  3. 80076(a)(18) - Food Service - Foods shall be protected against contamination, and contaminated foods shall be discarded immediately
  4. 80087(a) - Buildings and Grounds: The facility shall be kept clean, sanitary and in good repair at all times.
  5. 80075(k)(1) - Health and Services - The following requirements shall apply to medications which are centrally stored: Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
  6. 80065 (f)(7) - All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. The licensee of a Group Home or Adult Residential Facility that has been approved by the Department to utilize secured perimeters shall meet the staff training requirements as established by the Health and Safety Code section 1531.15(e) and the California Code of Regulations, Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56070(b).
A copy of the report was provided to administrator Myrna Brownell and HM Sherwin Magallanes.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3