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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201009
Report Date: 02/27/2024
Date Signed: 02/27/2024 05:31:06 PM

Document Has Been Signed on 02/27/2024 05:31 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:
02/27/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Myrna BrownellTIME COMPLETED:
05:35 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 Program Analyst, Manuel Monter conducted an unannounced continuation of the required annual visit of the facility. The initial annual inspection was conducted on 2/15/2024 by LPA Partoza.

The purpose of the visit is conclude the annual inspection and deliver the deficiencies and technical assistance's observed during the initial visit. Due to time constraint LIC 809-D and technical assistance was not issued. Today 2/27/2024 LIC 809-D and technical assistance are being issued based on the observation from the initial inspection as noted below.

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.

Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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 4
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: 02/27/2024
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
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, Sub chapter 4, Article 12, Section 56070(b).

LPA reviewed 3 resident P&I records.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways

An exit interview was conducted and discussed with House Manager (HM), Sherwin Magallanes. A copy of the report and appeals rights were provided.

Page 2 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/27/2024 05:31 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/27/2024 at 04:07 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: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
80087(a) - Buildings and Grounds: The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
ADM stated she will send a written plan of action to address the broken smoke detectors and bedroom #2's closet door. ADM will also send a written plan of action on how the facility will ensure facility bathrooms will be kept clean and sanitary at all times.
8
9
10
11
12
13
14
Based on observations,facility bathroom#2 had mold in the grout. Bedroom #3 had a broken smoke detector. Bedroom #2 closet door handle is missing. The sliding door by the covered patio is not in good repair. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
ADM stated she will send photo documentation the POC's have been completed.

ADM stated plan of correction (POC) will be submitted by 2/28/2024.
Type A
02/28/2024
Section Cited
CCR80087(g)

1
2
3
4
5
6
7
80087(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by
1
2
3
4
5
6
7
ADM stated she will send a written plan of action on how the facility will ensure disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger are inaccessible to residents in care.
8
9
10
11
12
13
14
Based on observation, Laundry detergent and cleaning solutions were located in the garage, exterior walkway by the garage exit door, under the sink & staff bathroom, accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee stated the plan of correction (POC) will be submitted on the 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/27/2024 05:31 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/27/2024 at 04:49 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: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
80075(k)(1) - Health and Services - The following requirements shall apply... Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
ADM stated she will send a written plan of action on how she will ensure medications are kept in a safe and locked place, inaccessible to residents in care.
8
9
10
11
12
13
14
Based on observations, medications in the office desk drawer and entertainment cabinet were accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
ADM stated the plan of correction (POC) will be submitted on the due date, 02/28/2024

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4