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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:23:49 PM

Document Has Been Signed on 04/20/2023 12:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROWN STREET HOUSEFACILITY NUMBER:
496801902
ADMINISTRATOR:GILLION, CHRISTINAFACILITY TYPE:
735
ADDRESS:112 BROWN STREETTELEPHONE:
(707) 568-5204
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15CENSUS: 15DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Christina GillionTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Christina Gillion.

Upon arrival, LPA observed that staff continue to wear masks and request that visitors do so as well. LPA discussed the recent PIN that allows facilities to discontinue mask wearing but facility has opted to continue to have staff and visitors mask and encourage residents to mask as well. LPA confirmed with Administrator that clients have the right to not wear a mask if they choose. LPA communicated to Administrator that requiring masking for visitors would require an update to the Admission Agreement and residents would need to agree to it. Additionally, facility is required to update their Plan of Operation/Infection Control Plan to outline what their policy is around masking and screening. LPA initiated a tour of the facility around 9:20am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathrooms measured at 113, 115, and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Shed containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked.

Fire extinguisher was last inspected May 2022. Facility had a fire inspection on 4/17/2023 and one smoke detector was found to be not working. The vendor that maintains the fire system has a planned service date to repair detector. Carbon Monoxide detectors located throughout the facility were tested and operational.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROWN STREET HOUSE
FACILITY NUMBER: 496801902
VISIT DATE: 04/20/2023
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Continued from LIC809

Five staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Cristina Gillion 6065002735, expires 1/2/2025. Medications and medication records were reviewed.

Licensee/Administrator to submit updates of the following documents by 5/20/2023:
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan to include new guidance for masking, screening, isolation and quarantine

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

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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