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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800394
Report Date: 12/28/2021
Date Signed: 12/28/2021 07:30:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/28/2021 07:30 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BROWN BOARD & CAREFACILITY NUMBER:
565800394
ADMINISTRATOR:BETTINA BROWNFACILITY TYPE:
735
ADDRESS:1337 W. HILL STREETTELEPHONE:
(805) 483-9618
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 10CENSUS: 8DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Bettina BrownTIME COMPLETED:
06:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year Inspection at the facility. The LPA met Administrator Bettina Brown at 2:47 PM and explained the reason for today's visit. At 2:51 PM, the LPA, along the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Common Areas: The living room area and dining room area has sufficient seating for the residents and was free of obstruction. The carbon monoxide detector and smoke alarms in the common areas and bedrooms were tested and operational. The fire extinguishers were observed be charged but last serviced on 02/04/2020. The washer and dryer are in the laundry and were observed to be functioning. Cleaning supplies are locked in a closet. The backyard has a covered outdoor area equipped with furniture for resident use.

Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored. There are two refrigerators that store food for resident use.

Common Restrooms: There are three restrooms for resident use. At 2:55 PM, the hot water temperature in the upstairs restroom measured at 141.6 degrees F. The water heater was turned down during the inspection. The restrooms were found to be clean and sanitary and operating condition with hand soap and paper towels.

Bedrooms: The five resident bedrooms were observed. Bedrooms were furnished appropriately with clean linens. A linen closet was located outside of the rooms, which stocked extra linens and towels.


Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BROWN BOARD & CARE
FACILITY NUMBER: 565800394
VISIT DATE: 12/28/2021
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Medications: Medications are locked and centrally stored in the closet of the Administrator's office. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications were recorded on the centrally stored medication and destruction record. Medications for four residents were reviewed. One out of the four residents' medication was observed to not be administered as prescribed as Resident #1's (R1) Benztropine Mesylate 1 MG medication card began being self administered on 11/23/21 pursuant to facility records, but the medication card still had 18 pills left. The Administrator and caregiver did not have an explanation as to how this occurred.

Records: At 4:05 PM the LPA began record review. Six out of eight resident files were reviewed. Files reviewed were found to be complete, except Resident #2 (R2) and Resident #3 (R3) were missing TB test results. Three staff files were reviewed and were found to be complete, except Staff #1 (S1) was missing a physical and TB results. Disaster drills are conducted at least every six months, the last drill being conducted on 07/10/2021.

Infection Control: During today’s visit, the LPA spoke with the caregiver regarding the facility’s infection control practices. The facility’s cleaning protocol is sufficient. Upon entry, the facility has a central entry point for symptom screening. LPA observed staff to be wearing a mask. The LPA observed an adequate supply of Personal Protective Equipment (PPE). If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were emailed to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/28/2021 07:30 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/28/2021 at 05:40 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROWN BOARD & CARE
FACILITY NUMBER: 565800394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2022
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 is not met as evidenced by:
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The administrator shall submit proof staff have received medication training to CCL by 01/04/2022.
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Based on observation and record review, the licensee failed to comply with the section cited above as one resident (R1) out of four residents did not receive their medication as prescribed which poses an immediate health risk to the resident in care.
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Type A
01/04/2022
Section Cited
CCR80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies (e) (1)Hot water temperature controls ..... used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
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The water heater was turned down during the inspection. The administrator shall submit proof of a five day water temperature log indicating the temperature is within the required range to CCL by 01/04/2022.
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Based on observation, the licensee failed to comply with the section cited above as the hot water temperature in one of the three restrooms measured at 141.6 degrees F which poses an immediate safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/28/2021 07:30 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/28/2021 at 06:07 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROWN BOARD & CARE
FACILITY NUMBER: 565800394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2022
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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The administrator shall submit proof to CCL the fire extinguishers have been serviced by 01/11/2022.
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Based on observation, the licensee failed to comply with the section cited above as the fire extinguishers were fully charged but had not been serviced since 02/04/2020 which poses a potential health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 12/28/2021 07:30 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/28/2021 at 05:50 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROWN BOARD & CARE
FACILITY NUMBER: 565800394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2022
Section Cited
CCR
80069(c)(1)

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80069 Client Medical Assessment (c) The medical assessment shall include the following:
(1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.
This requirement is not met as evidenced by:
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The administrator shall submit proof R2 and R3 have TB tests with results to CCL by 01/11/2022.
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Based on record review, the licensee failed to comply with the section cited above as two out of four resident files reviewed (R2 &R3) did not have TB tests with results which poses a potential health risk to residents in care.
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Type B
01/11/2022
Section Cited
CCR80065(g)(1)

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80065 Personnel Requirements (g) All personnel,..., shall be in good health,.. and occupationally capable of performing assigned tasks. (1).. good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physcian.....This requirement is not met as evidenced by:
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The administrator shall submit proof S1 has received a physical with TB results to CCL by 01/11/2022.
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Based on record review, the licensee failed to comply with the section cited above, as one out of three staff (S1) did not have a physical with TB results on file which poses a potential health risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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