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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:53:50 AM

Document Has Been Signed on 02/23/2022 11:53 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:
02/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Staff Member, Clairisse Daniels TIME COMPLETED:
12:03 PM
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Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct a Case Management visit and met with staff member, Clairisse Daniels, Administrator Shanice Moore was available by phone. Administrator has given permission for staff member to sign.

LPAs spoke with Administrator Shanice Moore regarding a medication error that occurred on 2/2/2022 for Client, C1. Per conversation with Administrator and review of incident report, the staff was temporary and was filling in due to staff shortage. C1 grabbed medication cup that had another client's medication in it and staff was unable to intervene in time. C1 did not have any adverse effects to taking incorrect medication.
Staff was retrained and facility updated their medication procedures to minimize the risk of clients grabbing the incorrect medication.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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Document Has Been Signed on 02/23/2022 11:53 AM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/23/2022 at 11:39 AM
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: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services: Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on interview and document review C1 took another client's medication. This poses an immediate risk to the health and safety to residents in care.
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Facility has changed their medication procedures and have retrained staff.

Deficiency is cleared.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
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