496801902-5-30-2024-21-AS-CFES-D5RTTW-20240530150124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:01:35 PM

Document Has Been Signed on 05/30/2024 03:01 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 HOUSE		FACILITY NUMBER:	496801902
ADMINISTRATOR/ DIRECTOR:	GILLION, CHRISTINA		FACILITY TYPE:	735
ADDRESS:	112 BROWN STREET		TELEPHONE:	(707) 568-5204
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 15		CENSUS: 15	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Administrator/Program Director, Christina (Chris) Gillion and Social Rehabiliation Director, Rita Larson		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	At approximately 8:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year visit and met with Staff Member, Arianna Santana. Administrator/Program Director, Chris Gillion, arrived during visit at approximately 8:35AM. Facility is a Long Term Social Rehabilitation home that provides care and assistance to Adults with Mental Health diagnoses. Facility has an approved fire clearance and capacity for 15 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 15 Clients in care and 2 staff members on-site. At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-through of the facility with Program Director and observed the following: Facility is a two story home with 8 bedrooms, 4 bathrooms, an office space, and common areas. Facility has an Infection Control Plan on file. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Toxins were secure and inaccessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. During walkthrough, LPA observed that facility does not have an evacuation chair on-site per Health and Safety Code (See technical advisory, LIC9102, H&S Code 1565(f)(1)). Facility's fire extinguishers were last inspected April 2024. Facility's last emergency/disaster drill was conducted April 2024. At approximately 10:55AM, LPA reviewed staff and client files, and client medications. Client files were all found to be well organized, thorough and contained the required documentation. During staff file review, LPA observed that 2 of 5 staff members did not have current First Aid certification as required (this deficiency has been cited, see LIC809D, regulation 80075(f)). Medication was centrally stored and secure. Facility does not manage P&I monies for clients. Administrator's Certificate for Christina Gillion (7029720735) was current with an expiration date of 01/02/2025. During walkthrough, LPA observed prepoured morning medications. Per conversation with Program Director, medications are poured during each shift, about one hour before administering to clients. LPA notified Program Director that pre-pouring medications is against regulation (See technical violation, LIC9102, 81075(k)(6)). Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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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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: 05/30/2024

NARRATIVE

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Continued from LIC809

Social Rehabilitation Director, Rita Larson, arrived during visit at approximately 1:15PM.

LPA also followed up on a self-reported incidents that were submitted to Community Care Licensing (CCL).
Incident Report 1: CCL received an incident report on 04/16/2024. Report stated that on 04/13/2024, Resident 1 (R1) reported to facility staff that they were hearing voices that were telling them to kill themselves and their roommate. Facility contacted emergency personnel who determined that R1 needed to be evaluated. Facility made all appropriate notifications per regulation.

Per conversation with Program Director, R1 is currently out of the facility receiving treatment.

Incident Report 2: CCL received an incident report on 04/16/2024. Report stated that on 04/13/2024, Resident 2 (R2) did not return from an outing. Report stated that R2 returned to the facility on 04/15/2024. Facility made all appropriate notifications per regulation.

Review of R2's physician report stated that R2 is able to leave the facility unassisted.

LPA requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Updated Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Current and Active Administrator's Certificate

Documents to update facility file to be submitted to Community Care Licensing (CCL) by due date of 06/30/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Social Rehabilitation Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2024 03:01 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 05/30/2024 at 02:43 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROWN STREET HOUSE	FACILITY NUMBER: 496801902
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review, the Licensee did not comply with the section cited above for 2 of 5 staff files and did not ensure that staff members had current First Aid and/or CPR certificates. This poses an immediate health, safety or personal rights risk to Clients in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that First Aid and CPR Training will be conducted for all direct care staff by POC due date of 05/31/2024. Licensee to submit Proof of First Aid and CPR certificates to CCL by POC Due Date of 06/10/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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