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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:42:02 PM

Document Has Been Signed on 10/21/2022 12:42 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:MOORE, SHANICEFACILITY TYPE:
735
ADDRESS:112 BROWN STREETTELEPHONE:
(707) 568-5204
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15CENSUS: 15DATE:
10/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:House Manager, Chris GillionTIME COMPLETED:
12:51 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with House Manager, Chris Gillion. Administrator, Shanice Moore was available by phone.

Facility recently reported that seven clients were mistakenly given their PM medications during the noon medication pass. Per discussion with House Manager, they previously implemented the "Seven Rights of Assisting with Self-Administration of Medication" which teaches staff to ensure that medication is administered at the correct time but the protocol was not followed.

LPA also discussed the "pre-pouring" of medication with the House Manager because centrally stored medication must be stored in its originally received container. Per discussion, the facility protocol is to prepare medications for the next medication pass one to two hours in advance but staff are not supposed to pour medications for multiple medication passes. The fact that the PM medications were poured prior to lunch is not facility protocol.

LPA agreed to obtain clarification about whether facility may pour medication an hour or two in advance per their protocol.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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 10/21/2022 12:42 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 10/21/2022 at 12:17 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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement has not been met as evidenced by document review showing that 7 out 15 clients were given medication at the incorrect time. This is an immediate risk to the health and safety of clients in care.
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Facility has addressed the situation and further correction is not needed. 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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