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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701316
Report Date: 06/10/2024
Date Signed: 06/10/2024 09:37:02 PM


Document Has Been Signed on 06/10/2024 09:37 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BROWN LOVING CARE LLCFACILITY NUMBER:
502701316
ADMINISTRATOR:MORENO DE BROWN, LAURAFACILITY TYPE:
740
ADDRESS:6616 GRAYBARK LANETELEPHONE:
(209) 883-7099
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:6CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:BrownTIME COMPLETED:
01:55 PM
NARRATIVE
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On 6/10/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced visit on this date. LPA met with Mr. Brown.

The purpose of the visit today is in response to a request to change the office to a resident room. The facility submitted required documents including a new facility that identifies the room as a resident's room. The facility did not require a new fire clearance. The fire clearance included utilization of all rooms as resident quarters.

During the visit LPA toured the facility and observed debris in the garage blocking the walkway leading to the door. (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

An exit interview was conducted, and a report was left with the facility with appeal rights.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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Document Has Been Signed on 06/10/2024 09:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BROWN LOVING CARE LLC
FACILITY NUMBER: 502701316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2024
Section Cited
CCR
87307(d)(6)

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(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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The facility will remove the items blocking the walk way in the garage and maintain the clear paths to all exit. The facility will send pictures of the clear paths in the garage by POC date 6/17/2024
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This requirement is not met as evidenced by observation and photos taken debris in the garage is blocking the walkway leading to the exit door.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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