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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201009
Report Date: 08/16/2024
Date Signed: 08/16/2024 12:15:39 PM

Document Has Been Signed on 08/16/2024 12:15 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/
DIRECTOR:
BROWNELL, MYRNAFACILITY TYPE:
735
ADDRESS:2019 SHELLBACK PLACETELEPHONE:
(408) 259-2969
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Veronica Pantano - Lead StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst Maria Partoza conducted an unannounced case management - deficiencies visit and was met by three staff. Staff 1 (S1) Veronica Pantano, is the lead staff (LS) for the facility, called the licensee/administrator (LIC/ADM) Myrna Brownell. LPA spoke to LIC/ADM over the phone, who stated that she is currently accompanying and assisting a resident with their doctor's visit at Kaiser and have authorized and designate S1/LS to sign for the report during today's visit.

The facility is licensed to serve adults ages 18 to 59 years old of which 2 may be non-ambulatory.

At 11:20 a.m. LPA with S1/LS toured the facility inside and outside including but not limited to resident bedrooms, kitchen, bathroom, living room, activity room, dining area, the backyard area and garage.

LPA observed that toxic, cleaning supplies, laundry detergent, medications, sharps and knives were in a locked and secured cabinet. The resident's bedroom observed to be sanitary, organized, free from obstructions and have sufficient storage for the resident's personal belongings. Walkways and hallways are free from obstructions. LPA observed that the bathroom by the hallway was sanitary and organized. The water temperature was tested and measured at 109.4 degree F to 109.9 degree F.

LPA reviewed 3 of 3 staff record, and observed that all have fingerprint and criminal background clearance. 3 of 3 staff have 1st aid CPR training.

No deficiencies were cited during today's based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with S1/LS Veronica Pantano and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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