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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:19:11 AM

Document Has Been Signed on 05/12/2022 10:19 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROWN STREET HOUSEFACILITY NUMBER:
496801902
ADMINISTRATOR:MOORE, SHANICEFACILITY TYPE:
735
ADDRESS:112 BROWN STREETTELEPHONE:
(707) 568-5204
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15CENSUS: 12DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Administrator, Shanice MooreTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Administrator, Shanice Moore. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility and the facility's visitation protocol. Once inside, LPA observed a screening station that included a thermometer and a log to track client and staff daily temperatures. Also observed were disinfecting wipes. Per conversation with staff and Administrator, the clients don't get a lot of visitors and those who do tend to visit outside. LPA confirmed with Administrator that if a visitor wanted to visit with a client indoors, that staff will screen them and conduct vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 9:10am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located in common areas. Facility has bathrooms throughout with supplies for hand washing. Observed staff and many clients had masks on during this visit. Commonly touched surfaces are disinfected twice per day.

Facility has visiting areas outside. Staff have completed PPE training and facility has provided a round of N95 fit testing but will be conducting additional testing for new staff and those who may be coming up on their one year anniversary.


Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROWN STREET HOUSE
FACILITY NUMBER: 496801902
VISIT DATE: 05/12/2022
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Continued from LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2021. Per conversation with Administrator, they have an appointment to have the fire extinguishers serviced by the end of the month. Facility has a fire system that is connected to the local fire department and is tested yearly by the fire department. LPA is unable to test the system. Four out of four Carbon Monoxide detectors were tested and operational.

Administrator and LPA discussed their Emergency Disaster Plan and Administrator showed LPA their Infection Control Plan which will be submitted to CCL by June 30, 2022.



Administrator to submit updates of the following documents by 6/12/2022:

LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Clients

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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